10-6-20-5M
^SENTEo j.
The New V
of Medicine
By
, ^4<at .
4
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3^ournal of tfje
3otoa ^tate Jfliebical ^ocict|>
INDEX
Volume XII, January to December
1Q22
EDITOR
D. S. FAIRCHILD. M.D., Clinton
i THE N, Y, ACAULMY
BUSINESS MANAGER j pp > V O
T. B. THROCKMORTON, M.D., Des Moines ^
I t.iAR i 0 1923
/ 7 r 2 s •
PUBLICATION COMMITTEE Ij LlB^Ah t
D. S. FAIRCHILD, M.D., Clinton \V, L. BIERRltfEv SiBL, Des Moines ’ ^
C. P. HOWARD, M.D., Iowa City
INDEX
19 2 2
A
PAGE
Abdomen, The acute, Edward F. Beeh 80
Act for the promotion of the welfare and hygiene of mater-
nity and infancy, and other purposes — 67th congress 68, 70
Action for services rendered non-resident patient 377
Adenoids and eye strain in school children — why many leave
school, Percy R. Wood 45i
Advertising in Medical Journals (Ed.) 1.58
.Mkaline phosphates in health and disease. Role of, J. Henry
Dowd 60
American College of Surgeons, Standardization program of... 155
College of surgeons. Official bulletin of (Ed.) 50f<
Program of, Franklin Martin 493
American Medical Association, The question of representation
in the sections of the House of Delegates (Ed.) 507
Association of Vienna 509
Urological association 511
Anemia, Pernicious, Study of one hundred twenty-seven cases.
F. T. Rohner 216
Treatment of. Present status of, Philip B. McLaughlin. . .214
Types of severe, with special reference to secondary
hypoplastic, Alfred Stengel 208
-Anesthesia, Combined, Charles Ryan 181, 230
-Anesthetic, New local 122
-Angioma by radium, Treatment of 377
-Angina pectoris. The effect of occlusion of the coronary
arteries on the heart’s action and its relationship to.
Warfield T. Longcope 314
-Annual collection, The 506
-Appendicitis, The causes of failure of operations for chronic,
Charles J. Rowan 322
Chronic, treatment and complications following operations,
George Kessel 437
Diagnosis of, M. J. Kenefick 440
Army medical department. Needs of 193
AUTHORS—
-Acher, .A. E
Armentrout. Coral R
-Armstrong, Margaret
Bailey, Fred W
Bainbridge, William Seaman
Barnes, Arlie L
Beach, Lena -A
Beeh, Edward F
Bendixen, P. A
Bevan, Arthur Dean
Beye. Howard L
Billings, Frank
Christian, Henry A
Conkling, Wilbur S
Davis, Edward P
Dean, L. W
Decker, George E
Deering, -Albert B
Dowd, J. Henry
Downing, Jamel M
262
362
187
222
354
81
407
89
489
500
40
171, 307
4.58
351
6
360
58
60
446
Eiker. B. L
Ely, Frank A. . . .*.
Enfield, Charles D
Evans, Evan S
Fairchild, D. S
Fay, Oliver J
Galloway, Milton B
Gaylord. Harvey R
Gittings, J. Claxton
Harkness. G. F
Harned, Calvin W
Harpel, Kate S
Hennessey, F. -A
Hibbs, F. V
Howard, Campbell P
-Jackson, Edward
Tacobaeus, H. C
Kenefick, M. J
Kessel, George
Lamb, F. H
Lapsley, Robert M
Latchem, Robert L
Leader, Pauline
Lemon, Willis S
Longcope, Warfield T . - - .
Lowrey, Lawson G
Luginbuhl, C. B
McAtee, John S
McCrae, Thomas
McLaughlin, Philip B
Marshall, Victor F
Martin, Franklin
Martin, John Walter
Mayo, William J
Morgan, John J. B
Morris, Robert T
Morrison, O. C
O’Donoghue, Arch F
Patton, James M
Pond, A- M
Reeder, James E
Robertson, H. E
Rock, J. E
Rohlf, E. L
Rohlf, W. -A
Rohner, F. J
Rowan, Charles J
Ryan, Charles
Secoy, Frank L
Shellito, A, G
Shuman, John W
Stengel, Alfred
Stoner, A. P
Swanberg, Harold
Sylvester, Reuel H
Throckmorton, Jeannette F
Tinley, Mary L
Voldeng, M. Nelson
PAGE
479
259
44
427
22, 103, 147, 267, 375
481
13
21
391
224
10
265
498
54
1
131
432
440
437
410
39
449
366
81
314
100, 396
96
15
248
211
138
496
484
243
396
53
404
141
387
- - 205
136
503
326
329
169
216
322
181, 230, 332
50
179
374
208
145
442
330
184
49
175
Volume XII, 1922
INDEX
PAGt
Wahrer, F. L 370
Ward, D. W 143
Will, Frank A » 430
Winnett, Edwin B 47
W'olfe, Otis R 370
Wood, Percy R 451
Woodward, L. R 319
B
Bile passages. Surgical injuries to the, A. E. Acher 262
Book publishers. Trials of (Ed.) 65
BOOK REVIEWS—
Abdominal pain 424
Allen treatment of diabetes « 38
Bacteriology, Textbook of general 303
Bulletin of the State University of Iowa . .ad. p. xvi, Mav
Cataract, A treatise on ad. p. xvi, Feb.
Christian science. What is it ad. p. xvi. May
Clinical diagnosis 305
Clinical laboratory methods. Manual of 47S
Clinical tuberculosis •. 349
Digestive organs with special reference to their diag-
nosis and treatment. Diseases of 47G
Diseases of the eye 304
Of the skin 80, ad. p. xvi, Feb.
Of the skin and eruptive fevers ad. p. xvi, June
Neoplastic ad. p. xiv, June
Dorland’s American illustrated dictionary 349
Epidemiology and public health 124
Essays on surgical subjects ad. p. xxviii, Jan.
Eye, ear, nose and throat nursing i... 38
Hay-fever and asthma, care, prevention and treatment 477
Henle, Jacob, Life of 204
History of medicine 122
Hygiene, Principles of 80
Infant feeding ad. p. xvi, Sept.
Practical 424
The management of the sick 477
McDowell, Ephriam- — “Father of Ovariotomy” and
founder of abdominal surgery 123
Master of man. The 38
Mayo foundation. Papers from the 302
Mayo clinic. Collected papers of 167
Medical clinics of North America,
350, 478, ad. p. xvi, Jan. ; xxviii, Feb. ; xvi. May
Department of the United States Army in the
world war 306
Electricity and roentgen ray and radium 168
Surgical reports of the Episcopal hospital of Phil-
adelphia 3Q6
Treatment, Principles of 204
Mind, An essay on the physiology of the 303
Neoplastic diseases ad. p. xiv, June
Nostrums and quackery ad. p. xvi, Jan.
Opiate addiction — its handling and treatment 476
Pathology, General ’. 124
Peripheral nerves, Surgical and mechanical treatment
of 425
Physician himself from graduation to old age. The.... 350
Pitfalls ad. p. xvi. Sept.
Proceedings of the fifteenth annual meeting of the
association of life insurance presidents,
ad. p. xiv, June
Psychoanalysis 303
South America from a surgeon’s point of view 305
Spleen and some of its diseases. The 79
Surgeon of the public health service. Annual report of 305
Surgery, Operative 37
Surgical anatomy ad. p. xvi, Feb.
Clinics of North America,
38, 204, ad. p. xvi. May; xvi. Sept.; xvi-xxviii, Jan.
Submucous resection of the nasal septum 304
Syphilis in its relation to pregnancy and infant death.. 426
Thyroid gland. The 425
i’ll
PACE
Transactions of the College of Physicians of Phila-
delphia 305
Tuberculosis in infancy and childhood 426
Version in obstetrics. The place of 476
Visceral disease. Symptoms of 478
Botulinus, New organisms akin to (Ed.) 193
Blood, The relation of the splenic syndromes to pathology
of the, William J. Mayo 243
Brachial birth paralysis (Ed.) 417
Breast, the human, A plea for a well directed treatment based
upon a more accurate diagnosis, William Seaman
Bainbridge 354
British Medical Association (Ed.) 152
medical journals, Early (Ed.) 152
Bronchi, The diagnosis of foreign bodies in the, Thomas
McCrae 248
C
Caesarean Section, Our present knowledge and experience
concerning, Edward P. Davis 351
Unusual indication for — case report, Albert B. Deering 58
Cancer, American society for the control of, Harvey R. Gay-
lord 21
Carbon monoxide poisoning, Treatment of (Ed.) 200
Cardiac diseases. Digitalis in, Henry A. Christian 307
Cardio-vascular and renal diseases. Retinal changes in, James
E. Reeder 136
Childhood, The occult diseases of, J. Claxton Gittings 391
Chiropractors (Ed.) 381
Clinics, Pay 157
Colitis, Chronic, C. B. Luginbuhl 96
Constitution and by-laws Iowa State Medical Society 468
Cord, Injuries to the spine not involving the, Oliver J. Fay. . .481
Involvement, Vertebral fractures with, John Walter
Martin 4,84
Coronary arteries on the heart’s action and its relationship to
angina pectoris. The effect of occlusion of the. War-
field T. Lougcope 314
Crouse, Dr. Eugene A 239
D
Damages involved in failure to use x-ray in fracture of
femur. Question of 199
Dangers to x-ray operators (Ed.) 157
Dead and wounded in German empire in world war 157
Defense fund. Rules governing the members of the Iowa State
Medical Society with reference to the (Ed.) 29
deSchweinitz, Dr., Address of acceptance as president-elect
of the American Medical Association (Ed.) 461
Des Moines as a medical center 419
Diabetes, Treatment of, Edwin B. Winnett 47
Diabetics, The hospital and laboratory in the treatment of,
E. L. Rohlf 329
Digitalis in Cardiac Disease, Henry A. Christian 307
Diseases of the blood-vessels as seen in the eye, Edward
Jackson 131
of childhood. The occult, J. Claxton Gittings 391
Division of Fees (Ed.) 157,335
Druggists and physicians 122
E
Ectopic gestation, as a vital subject to the patient and practi-
tioner, Coral R. Armentrout 362
Editors special journals published by the A. M. A., Election of 198
Embargo on German dyes and synthetic drugs and chemicals
(Ed.) 415
Empyema, Higbmorian, Frank L. Secoy 50
Encephalitis lethargica. Precautions against (Ed.) 110
Epilepsy, Luminal in treatment of — preliminary report, M.
Nelson Voldeng 175
Ethics in fractures, F. A. Hennessey 498
Of fracture cases (Ed.) f 508
Evangelist and healer. The new (Ed.) '. Ill
IV
INDEX
Volume, XII, 1922
Female pelvic organs. Conservative surgery of, A. G. Shellito 179
Focal infection in genito-urinary tract, John S. McAtee 15
Mouth, teeth, tonsils and maxillary bones in relation to
systemic disease, Calvin \V. Harned 10
Nose and throat, L. \V. Dean 6
Foreign bodies in the bronchi. The diagnosis of, Thomas
McCrae 248
Foreigners as assistants in Italian clinics 509
Fowlers solution (Ed.) 336
Fracture cases. Ethics of (Ed.) 508
Fractures, Mistakes in the treatment of, Howard L. Beye....500
Fractures, The treatment of. O. C. Morrison 404
Franklin, Benjamin as a medical contributor (Ed.) 416
Funds for medical college 116
G
Gastrointestinal infections, M. B. Galloway 13
Gorgas memorial institute of tropical and preventive med-
icine (Ed.) 65
Group practice (Ed.) 116
H
Headaches, Nasal, Otis R. Wolfe and F. L. Wahrer 370
Hernia, The economic position of (Ed.) 334
Report of special committee on traumatic and industrial,
American Railway Association (Ed.) 336
Homeopathy in state universities (Ed.) 381
Hospital for insane, Observations of a woman physician in,
Pauline JI. Leader 366
And laboratory as an aid in diagnosis and treatment of
diabetics, E. L. Rohlf 329
At Camp Dodge, The new (Ed.) 112
Standardization, its inception, development and progress
in five years 114
from the viewpoint of the hospital trustees 295
from the viewpoint of the hospital superintendent. ... 197
report of the recommendations of the American Rail-
way Association in connection with 341
Relation to obstetrics, Mary L. Tinley 49
Standardizing of hospitals urged 465
Survey of the college 154
Hospital news, 34, 77, 120, 162, 202, 237, 300, 348, 386, 421, 464, 513
Hospitals, New York 158
Hyperthyroidism and the basal metabolism test. The radiation
treatment of. Harold Swanberg 442
Hydronephrosis, Trauma as a factor in etiology of (Ed.) 414
Hynson, Westcott & Dunning, new home 516
I
Immunologic experiments with streptococci from influenza
(Ed.) 66
Important announcement, Abbott laboratories 506
Infantile paralysis, diagnosis and treatment, Arch F.
O’Donoghue 141
Infections of the abdomen. Acute, D. W. Ward 143
Gastrointestinal, M. B, Galloway 13
In the genitourinary tract. Focal, John S. McAtee 15
Of the mouth, teeth, tonsils and the maxillary bones in
relation to systemic disease, Calvin W. Harned 10
The nose and throat. Focal, L, W. Dean 6
Prevention of puerperal (Ed.),... 28
Infectious jaundice 500
Injuries to the spine not involving the cord, Oliver J. Fay. . . .481
Insurance in England, Some dissatisfaction with national (Ed.) 194
Intracardiac injection of adrenalin in heart arrest (Ed.) 270
Iowa State Medical Society (Fid.) 151
Constitution and by-laws 468
Seventy-first annual session (Ed.) 232
Iowa State L’^niversity news,
30, 68, 115, 153, 196, 234, 272, 345, 418,462
Italian clinics. Foreigners as assistants (Ed.) 509
Italy during the war, Losses in the profession in 159
PAGE
J-L
Japanese medicai men
Laboratory practice of medicine. The, H. E. Robertson 503
Langworthy, Dr. Henry G
Liability insurance. Increased cost (Ed.) 453
Luminal in the treatment of epilepsy, a i>reliminary report,
M. Nelson Voldeng
M
Malpractice case in New York (Ed.) 343
Marriages 37, 79, 122, 386, 422, 467, 516
Maternity bill (Ed.)
Medicine courses, Kentucky physicians oppose shorter 267
Medical education. President Lowell on high cost of (Ed.).. 385
Examiners, -National board of 1 231 506
Ideals, Evan S. Evans
Practitioner, The passing of the, Campbell P. Howard 4
Problems in Iowa, A. M. Pond 205
Profession, The, Frank Billings 4Q
Medical news notes 35, 67, 116, 159, 200, 235, 296, 384, 463
Medicine and politics (Ed.) 493
-Medicine. The laboratory practice ofj H. E. Robertson .303
Mehler. Dr. F. C 27
Memorial to Dr, Sato
Mental measurement in relation to medicine,' Reuel H. Syl-
vester
Standardization, A practical discussion, of, Frank A, Ely. .259
Mistakes in the treatment of fractures, Howard L. Beye 5C0
Myocarditis, and nephritis. The relation that exists between
hypertension, Henry A. Christian 474
N
Nephritis, Renal functional tests in chronic, F. H. Lamb 410
Neuropsychiatric problems of disabled veterans (Ed.) 334
New and non-official remedies,
168, 306, 457, adv. p. xxviii. Jaru-Feb. ; adv. p. xvi, Oct.
Nurses, Training of (Ed.) 113
O
OBITUARY—
Bailey, Pearce 242
Baker. Frederick 34s
Baldwin, Gilbert 79, 121
Blech, Gotthilf 34s
Bonney, Albert Franklin, 467
Buchanan, Robert E 203
Burke, Charles D 302
Chamberlain, H. D 121
• Cooling, William A 203
Courtright, Harry L 386
Craig, Alexander R 385,515
Criley, B, H 241
Croston, Thomas 466
Crowder, William M 104
David, Joseph W 240 •
Day, George L 424
DeVore. Leonard 240
Dinsraore, David C 37
Doan, Henry C 516
Drake, Franklin J 467
Ely, William E 165
Feenstra, J. B. H 240
Fleming, Nancy 424
Grigsby, W. E 104
Groom, James W 165
Hannelly, Michael F. 460
Hartman, Mrs. Effie Alice 240
Harvey, Phillip Francis 466
Heilman, Elwood C 514
Hilbert, Melancthon 423
Jaynes, E. T 423
Jenkins, Edmund R 301
Kreider, George N 242
7
/
Volume XII, 1922
INDEX
V
PAGE
Layman, Daniel \\* .* 241
Layton, Harry K 242
Little, K. H 122
McCroskey, James A 240
McDermid, Pierre 242
McKone, John \V 423
MacDonald, Joseph 241
Mehler, Frank R 51G
Morford, Cornelius M 121
Myers, William II 165
Xevins, John 164
Park, Lewis E 515
Peters, A. II 510
Power, Claude 241
Rawlins, John A 467
Richter, Herman A 241
Roberts, Thomas G 240
Shreve, B. F 121
Smith, Edwin E 348
Spafford, Frederick A 242
Spaulding, George A 424
Sprague, Theophilus 515
Stanton, John H 302
Stewart, Benjamin C 466,514
Stong, Jesse F 165
Swigert, Daniel W 466
Wade, Charles M ...164
Wailes, J. S 24 1
Weston, Sarah J 466
White, John 122
Winters, O. G 302
Wyeth, John Allan 386
Obstetrics, Relation of hospital standardization to, Mary L.
Tinley 49
Ophthalmology and the lesser alcohols, James M. Downing. . .446
Oration on medicine, B. L. Eiker 479
Oration in surgery — Do we progress, W. Rohlf 169
Orphans need help 513
P
Pekin medical college (Ed.) Ill
Pellagra in the southern states (Ed.) 196
Perichondritis of laryn.x with report of case. Acute, Frank A.
Will 430
Peritonitis, Pneumococcus, X'ictor F. Marshall 138
Perkins* tractors (Ed.) 378
Personal mention.
36, 78, 120, 163. 203, 238, 301, 347, 385. 421, 465, 512
Physical census of the male population (Ed.) 194
Physicians honored, American 158
Chicago 158
Physicians who located in Iowa in the period between 1850
and I860, D. S. Fairchild 22,103,147,267,375.
Pneumococcus Peritonitis, X’ictor F. Marshall 138
Pneumonia, Incidence of (Ed.) 66
Pneumothorax. Clinical study of fifty cases, XX^'iHis S. Lemon
and Arlie L. Barnes 8i
PORTRAITS—
Calkins, Martin II 117
Chase, Charles Sumner 26
Chase, Sumner B 25
Crouse, Eugene A 230
Field. Archelaus G 104
Mehler. Frank C 27
Pond. Alanson M 125
Robertson, XX'illiam S 23
Stanton. John II 302
XX’arden. Charles Chunn 267
President’s .Xddress — Medical Society Missouri X’alley, Chas.
Ryan 332
Priestley, James Taggart 380
Testimonial Dinner 452
PAGE
Program of the American College of Surgeons, Franklin Martin 496
Prostatectomy suprapubic; technic and after results, George
E. Decker 360
Protein injections in affections of the eye. Pros and cons of
foreign, James M. Patton 387
Psychiatric analysis of the children in the state juvenile home,
Lawson G, Lowrey and John J. B. Morgan 396
Psychopathic hospital, Plan of the medical and research
service of the Iowa State, Lawson G. Lowrey 100
Public health. A bill to recognize and to promote efficiency
of the U. S. public health service 70
Bureau circular Xo. 323 116
Educational phase of, Jeannette F. Throckmorton 184
Movement, Brief history of, Lena A. Beach 407
Physicians active in 457
Service (Ed.) 64
Pyelitis, F. X'. Hibbs 54
R
Radiotherapy in certain forms of uterine fibroma (Ed.) 269
Radium in Congo 344
Insurance ( Ed.) 419
Radius, Fractures of the lower end of, P. A. Bendixen 252
Renal tuberculosis (Ed.) 269
Retinal changes in cardio-vascular and renal diseases, James
E. Reeder 136
Report of the recommendations of the American Railway
Association in connection with hospital standardization 341
Of the special committee on traumatic and industrial
hernia, American Railway Association 336
Rockefeller Board aids Brussels university 110
Rural doctors, Providing for the increase in the number of
(Ed.) 335
S
Sacro-coccygeal dermoids in relation to rectal diseases, signifi-
cance of, A. P. Stoner 145
Schick reaction, The (Ed.) 343
Schick test and active immunization against diphtheria (Ed.).. 63
Sheppard-Towner act, Iowa 460
Sheppard-Towner bill. Kate Harpel 265
Simmons, Dr. George II (Ed.) 507
Sinus disease. Some determining factors in nasal, G. F.
Ilarkness 224
Small-po.x in Kansas City (Ed.) 30
SOCIETY PROCEEDIXGS—
American Medical Association, Field Secretary 198
St. Louis meeting (Ed.) 120,270
Society for control of cancer ...231
Surgical association 464
Allamakee county medical society H
Appanoose county medical society 463
Audubon county medical society 51
.Austin Flint-Cedar X'alley medical society 31, 420
Boone county medical society 76,160
Botna X’alley medical society 51i
Bremer county medical society 71
Buena X’ista county medical society 463
Butler county medical society 71
Calhoun county medical society 12,160
Canada medical association 153
Chickasaw’ county medical society 52
Cerro Gordo county medical society 72,160,201,236
Clarke county medical society 32
Clay county medical society S3
Clinton county medical society 72,117,298
Davis county medical society 160
Decatur county medical society 72
Des Moines county medical society 72
Dubuque county medical society 73.201,345
Fremont county medical society 73, 117, 2'JS
Greene county medical society 117,345.420,463
Hamilton county medical society 160
VI
INDEX
Volume, XII, 1922
PAGU
Ilancock-W innebago county medical society 73, H i'
Hardin county medical society .aC9
Henry county medical society 73
Ida county medical society 74
Iowa clinical society 300,509
Iowa clinical surgical society 161, 464
Iowa and Illinois central district medical society 237
Iowa State Medical Society (Ed.) 151
Constitution and by laws 468
Des Moines session 130
Minutes seventy-first annual session 274
Officers and committees 294
Program seventy-first annual session 125
Report commitee on arrangements seventy-first
annual session 423
Seventy-first annual session (Ed.) 232
Transactions house of delegates seventy-first an-
nual session 276
Iowa x-ray club 517
Jackson county medical society 298
Jasper county medical society 74,117,510
Johnson county medical society 33, 74,236,464
Jones county medical society 420, 464,510
Keokuk physicians’ club 119
Kossuth county medical society 201
Lee county medical society 74, 118, 298
Linn county medical society 160, 298
Mahaska county medical society 74,118,160,299
Marion county medical society 75,236,345,510
Marshall county medical society 75,118
Medical women’s international association 347
Medicine, International society of 269
Mills county medical society 509
Milwaukee county medical society 79
Mississippi Valley medical association 119,385
Missouri Valley, Medical society, 35th annual session.. 349
Muscatine county medical society 75, 118
National health e.\position 27
Northwest Iowa medical society 34, 236
Orthopedic surgeons meet in Iowa City 34
Pacific northwest medical association 158
Page county medical society 346
Plymouth county medical society 236,463
l^ocahontas county medical society 464, 510
I’olk county medical society 118,385,510
Pottawattamie county medical society
Public health conference ‘
Radiological society of North America, Important res-
olutions adopted by ■
Ringgold county medical society
Scott county medical society 33,75,161,510
State society Iowa medical women 128,299
State university annual medical clinic. .Adv. p. xvi, March
Story county medical society 33,119,201
Southwest Iowa medical society 24,330
Tama county medical society 119,236,242,464
Taylor county medical society ‘5
fri-state medical society 237,382
I'rudeau society tuberculosis clinic, Iowa 120
Upper Des Moines medical association 76, 464
PAGE
\'.an Buren county medical society. . . .33, 76. 346, 420, 464
Wall lake district society 346
Wapello county medical society 33,101,236
Washington county medical society 119
Waterloo city medical society 119
Wayne county medical society 510
Webster county medical society 76, 202
Western electro-therapeutic association, .adv. p. xvi March
Woodbury county medical society 76,511
Specialists and the profession. Relation between the, Robert
M. Lapsley 39
Spine not involving the cord. Injuries to, Oliver J. Pay 481
Spirochetosis, Broncho-pulmonary (Ed.) 67
Splenic syndromes to the pathology of the blood. The relation
of William J. Mayo 243
State medical library 452
Surgery of the female pelvic organs. Conservative, A. G.
Shellito 179
Surgery, Outlook for fourth era of, Robert T. Morris 53
Surgical injuries to the bile passages, A. E. Acher 262
Syphilitic aortitis, a cause of sudden death, L. R. Woodward. .319
T
Tariff on microscopes and scientific apparatus. Proposed
(Ed.) 461
Testicles, Malignant growths in undescended (Ed.) 273
Thoracoscopy, its practical importance especially in surgery
of the chest. The, H. C. Jacobaeus 432
Thyroidism, Hypo and hyper, John W. Shuman 374
Tobacco, Evil effects of (Ed.) 417
Tonsil operation. The control of hemorrhage in, Fred W.
Bailey 222
Tooth brush tariff. Protest against proposed (Ed.) 385
Trauma as a factor in etiology of hydronephrosis (Ed.) 414
Tularaemia, Laboratory workers contract (Ed.) 199
Tumors involving the oral cavity, upper respiratory passages.
and ears and some observations following the use of
radium, Margaret Armstrong 187
Tumors of the breast from the standpoint of the general prac-
titioner and the general surgeon, Arthur Dean Bevan 489
U and V
Urological examination. Indications for, Raymond L. Latchem 449
Venereal disease. Consultation by correspondence on (Ed.)... 418
Venereal disease control. Report of bureau of, Wilbur S.
Conkling 458
Vertebral fractures with cord involvement. John Walter Martin 484
Veterans. Medical care for disabled (Ed.) •179
Vincent’s angina as seen in civil practice, J. E. Rock 326
W’
Wilbur, Ray Lyman, President American ^ledical .-Vssociation
(Ed.)
Women, Life of college bred
Workmen’s compensation law in New York amended
234
158
463
N
X-ray work in country practice, Charles D. Enfield 44
(E^fje Jfournal of tijc
3lotua ^tate jHetiical ^cietp
VOL. XII
Des Moines, Iowa, January 15, 1922
No. 1
THE PASSING OF THE MEDICAL
PRACTITIONER*
C. P. Howard, M.D., Iowa City
Why your program committee inflicted me
upon you to deliver the oration in medicine, I
confess I am at a loss to understand. However,
that may be, I must follow the example of my
betters and express the usual formal thanks for
the honor they have done me. Laying no claim
to oratory, I must ask you to nevertheless pardon
them, for I feel they had the best intentions in the
world and meant no harm to you. Indeed I am
sure they meant it for my good, though like most
“good intentions” they are very disagreeable for
the victim.
Medical teachers have a bad habit of being too
dogmatic, and too fond of laying down the law.
“Mea culpa” I must cry from the bottom of my
pedagogic heart. However, having warned you
of my tendencies, and having assumed your kind
forbearance, I will proceed with my task.
The twelve months that have elapsed since our
last annual meeting have been marked by a grad-
ual return to more normal peace conditions, at
least in the United States of America.
x\t first thought it has been a hopelessly dull
uneventful year in the medical world of America.
Yet has it? /\t no time in my twenty years of
practice has there been such a “Revival of Publi-
cation,” if not of learning as in this period. Two
new systems of medicine have appeared, each one,
no doubt, of great merit and including among its
contributors the active medical minds of America,
and Great Britain. Perhaps one would have suf-
ficed from the publishers standpoint, but from the
readers’ there is surely an advantage in having
this abundance of riches. I feel that perhaps of
greater value is the appearance of several new
journals edited and published in this country.
The Archives of Neurology and Psychiatry fol-
lowing late on the heels of the Archives of Inter-
nal Medicine, and the American Journal of Dis-
eases of Children, had more than fulfilled the
‘Presented before the Seventieth Annual Session Iowa State
Medical Society, Des Moines, Iowa, May 11, 12, 13, 1921.
high e.xpectations of its distinguished editorial
staff, and prepared a warm welcome on the part
of the medical, public for the Archives of Sur-
gery, the American Journal of Syphilis and the
Archives of Dermatology and Syphilology.
The two systems of medicine, we must confess,
are not pure American products, but are partly
Briti.sh and partly x\merican and serve as but an-
other example of the closer union and better un-
derstanding that have developed in these two
great countries between the members of the medi-
cal profession at least, as a result of the Great
W’ar. This, I take it is of good augury for the
future. I look forward to the day which is now
fast approaching (if not already here) when the
British graduate student will perforce come to
this country' to spend his “ Wander- Jahr” at our
various medical centers. W’hy should not a
definite program of such courses be arranged by
the x\ssociation of the American Medical Col-
leges, and published in syllabus form, as was for-
merly’ done in Germany and Austria.
x\s many of you know, some of the leading
British and ikmerican medical teachers have col-
lected money for an American hospital in London
and I believe are planning to make use of the
marvelously rich clinical material of the great
British metropolis. Lane, Rolleston and Bland-
Sutton are the British, while Crile, the two
Mayos, Ochsner, Alatas and Martin are the
American members of the council. Think of the
golden opportunity of listening to such clinicians
as Clifford Allbutt, Humphrey Rolleston, Rose
Bradford, Archibald Garrod, Norman Moore,
Byron Bramwell, Parkes Weber, Hale White and
of comparing their methods with those of our
leaders, Frank Billings, James Herrick, George
Dock, Lewellys Barker, Sydney Thayer, Henry
Christian, Thomas McCrae, Warfield Longcope,
Emanuel Libman, to mention only a few of the
various teachers of international fame.
Though the past year did not see a return of the
influenza itself, we have been visited again by
one of its “grizzley sisters,” or better perhaps
companions, as they are not in all probabilitv
blood relatives. I refer to the “epidemic encephal-
2
Journal of Iowa State Medical Society
[January, 1922
itis” or what was first called encephalitis lethar-
gica. This has been quite troublesome in certain
localities of the state, though I and the other
members of my staff have seen only some dozen
cases this year. While we were certain of its
infectious nature, its contagiousness was at first
thought only comparable to that of its first cousin
poliomyelitis. Yet quite recently Claude and de
Laulerie’^ report two cases who acquired the dis-
ease from contact in a hospital ward with con-
valescent cases of the disease, while Roger and
Blanchard- studied two recruits from the same
barrack who were simultaneously attacked. Again
the Local Government Board of England re-
ported an epidemic in one institution in which
twelve of twenty-one inmates were affected. In
discussing this question Xetter admits to a history
of contagion in 4.6 per cent of his patients.
Some claims have been made for a specific or-
ganism by various workers; that “jack of all dis-
eases,”— the streptococcus naturally coming in
for its share of accusers, among others, S. J.
House^. However, as in poliomyelitis it is prob-
ably a mere accident, and the true cause of the
disease is believed by the majority to belong to
the class of filtrable viruses. In am* event the
Berkfeld filtrates from the emulsified brain and
cord and even from the nasal mucosa, blood and
spinal fluid of human patients when introduced
into the brain, peritoneum, or nasal cavities of
monkeys, rabbits and guinea pigs have reproduced
the disease picture. (Levaditi,* Ottolenghi,^ IMc-
Intosh,^, Loewe and Strauss', Thalhimer®.) The
practical value of this work is claimed by Loewe
and Strauss®, who found that the nasopharyngeal
washings from cases of suspected encephalitis re-
produced the disease in rabbits when injected in-
tracranially in eleven out of fourteen cases or 78
per cent ; further that cultures of the spinal fluid
on special media have been positive in ten out of
twenty cases (50 per cent).
Much more widespread has been the epidemic
of Variola, both in this state and throughout the
Middle West. Dr. Don M. Griswold of the Di-
vision of Hygiene and Preventative IMedicine of
the College of Medicine informs me that during
the first three months of 1921 there were 2545
cases reported in Iowa and that if this rate per-
sists it will mean 10,000 cases for the calendar
year. This is an even higher rate than for 1920
which was nearly double that of former years
where preventative medicine had become lax.
This is the case in some of the European coun-
tries. In one province of Spain there were 300
cases reported with the high mortality of 44.
The Statistical Bulletin of the Metropolitan Life
Insurance Company, Januar}^ 1921, gives the
figures for five years in twenty of the states to
“show the increasing prevalence of the disease
.since the anti-vaccinationists began to intensifv
their campaign.” I do not want to preach or
criticize, but I cannot refrain from asking have
we forgotten the lessons of the past century or
even the wonderful lesson of the vaccinated
armies of the World War? The older practi-
tioners must surely recall the days of the con-
fluent small-pox in this country and the younger
ones must have acquired some faith in the army
vaccination regulations ; so that young and old
should know better. Why should the public be
allowed to grow up as an unvaccinated generation
only to be visited at some no distant period by this
dreadful, dangerous and disfiguring disease,
which is already gradually regaining its virulence
lost through its former years of struggle to keep
alive in a soil rendered unsuitable b)^ repeated
vaccination ? Are we blameless ? Have we not,
as health officers, school physicians and family
practitioners, winked at the laxity of the public,
who in their ignorance advance all sorts of
specious arguments against this simple rule of
preventitive medicine? Then when the horse is
stolen, we do not even lock the stable door ! The
rules of quarantine, infraction of which is a civil
misdemeanor are travestied. I will not shame you
with recounting all of my experiences in the last
few years. I cannot refrain, however, from tell-
ing you of the most culpable action of two practi-
tioners that occurred quite recently. A young girl
had been exposed to a case of small-pox and was
promptly vaccinated by the authorities and quar-
antined. One week went by when the girl de-
veloped malaise, headache and fever; the physi-
cian in attendance telephoned the girl’s father
who was also a physician that his daughter was
sick but whether with small-pox or local vac-
cinia, he was unable as yet to say. A request was
promptly sent in by the father to send her home,
as if it were merely local vaccinia, it would be all
right, while if it were variola, he could take care
of her. Yes, but what of the traveling public, to
say nothing of her home community? Had they
no rights ? I regret to report the attending physi-
cian let her go ! What happened as a result of
this, I am glad to say history does not relate. If
their excuse was ignorance, a loss of their license
should follow, if carelessness some fine or impri-
sonment.
Let us not forget that typhus fever is still prev-
alent in central Europe and some of it is bound to
be imported into this country and may reach us
even in Iowa within the next few months.
VoL. XII, No. 1]
Journal of Iowa State IMedical Society
3
The introduction of various methods of clinical
laboratory diagnosis has done more to place the
medical art among the sciences. The majority of
us in this association have had the good fortune
to see each year marked by some new method of
diagnosis, bacteriological, serological, chemical,
electrical or physical. Some have been of enorm-
ous value, some of doubtful value, and some of
no value at all. The former have come to stay,
the second will survive for a few years more, and
the latter are dropped almost immediately. This
is the history of ever}' science. We must re-
member that our fathers did not have these ad-
vantages and had to use other means to make a
correct diagnosis. W'hat were these ? A long and
careful history of the family, and the patient, a
long and detailed examination of the patient him-
self. What resulted? A category of symptoms
and physical signs. The next step was ro separate
the wheat from the chaff, the unimportant symp-
tom from the important, the valuable physical sign
from the valueless. This was the difficulty and
always required keen insight, cool judgment and
experience. 'However, the Sydenhams, the Jona-
than Hutchinsons, the Austin Flints, the Theo-
dore Janeway s and the William Osiers and a host
of others whom you and I could name, were able
to make astoundingly accurate diagnoses and to
treat their patients with great success by eyeing
askance the unimportant and superfluous and em-
phasizing the entire clinical picture. It W'as the
sum total that counted, not one positive symptom
or sign. With the introduction of elaborate ex-
aminations of the urine, the blood, the gastric
contents and the spinal fluid, a great advance w'as
made and diagnoses correspondingly improved.
This is a platitude you say, but the danger was
there in its embryonic state. Yet because these
methods were applied by the physician himself or
his young assistant, the results were properly cor-
related by the practitioner, surgeon or internist.
He w'ould say, the history of pain, nausea, vomit-
ing and slight fever and the physical signs of ten-
derness and muscle spasm speak for an acute ap-
pendix. I can afford to neglect the absence of a
leucocytosis. I will operate because experience
has taught me that it is more probable that the
history and a majority of the physical signs are
more valuable than the little understood mechan-
ism of immunity as represented by a leucocytosis.
Again the physician repeatedly concluded that the
family history, the previous and present history
of the patient together with certain well recog-
nized physical signs suffice to make a hard and
fast diagnosis of pulmonary tuberculosis without
the presence of tubercle bacilli in the sputum or a
positive tuberculin test.
Were not these methods of reasoning more cor-
rect and safer than the methods which are be-
coming the common practice of many today ? Oh,
you have a pain in the belly. You have a leu-
cocytosis and that means infection. Q. E. D. you
have an appendicitis and you must be operated
upon. Wliat about 'diseases of the lungs, the
pleura, the kidney and indeed such general in-
fections as influenza, which have abdominal pain
as a minor symptom, and may have other and
better means of treatment than exploratory in-
cision of the abdomen.
The practitioner of today, all too often, says to
a patient complaining of cough, sputum, and some
malaise — collect your sputum and we w'ill send it
to the laboratory' and I will let you know in a few
days whether you have tuberculosis or not. If a
negative report is received how much valuable
time is lost which could be saved by careful and
repeated examination of the lungs by the older
methods of inspection, palpation, percussion and
auscultation. Then comes a new method, the tu-
berculin test, (cutaneous, intradermai or subcu-
taneous) w'hich is at fii'st regarded by many as
the last court of appeal. It has taken almost
twenty years for a partial realization that a posi-
tive or a negative tuberculin test in itself is of no
more value than the absence or presence of any
one of the other symptoms or signs of the disease.
Finally the skiagram is touted as the short cut to
diagnosis of pulmonary tuberculosis, and we are
being lead by the nose by technicians and enthus-
iastic actinographers who are quite prepared ''O
make a diagnosis of phthisis upon the finding of
an increase in the hilus shadow or some fan-
shaped opacity in the periphery of the lung.
WYuld that such prophets know more about the
morbid anatomy of phthisis, anthracosis, pneu-
monia, thickened pleura, etc., before they become
so dogmatic. Have you ever stopped to consider
that a lagging movement of the chest wall, a
diminution of the tactile fremitus, an impairment
of the percussion note, a change in the respiratory
murmur, are four means of estimating alterations
in the transmission of sound w'aves, while the
x-ray plate reveals by one method only some in-
terference with the light waves? Important as
this latter information is, it should not be given
first place in the consideration of the case, but be
placed on an equal footing with the other physical
signs by the physician in charge who knows the
history, the other physical findings, the results of
the sputum, and tuberculin tests, and is therefore
in the better position to add up the positive and
negative symptoms, and to decide what the an-
swer is. Neither the clinical laboratory, nor the
x-ray room should be asked to make our diagnosis
4
Journal of Iowa State Medical Society
[January, 1922
for us, but to merely report the presence or ab-
sense of a test or a sign, which should be regarded
merely as a negative or positive symptom of the
disease. Let us bear this in mind or we will lose
the art of percussion and auscultation and depend
entirely on less constant and therefore less relia-
ble tests.
When the various clinical laboratory tests do
not accord with the history or physical findings
in our patient, it should be our first duty to re-
view the case history and repeat the physical ex-
amination with especial reference to the condition
suggested by the laboratory report, and if then
the history and physical findings can not be ac-
counted for by the condition suggested by the
clinical laboratory, ask for a second laboratory
test. It is surprising how frequently the labora-
tor}- is wrong, much more frequently than the
guileless and gullable medical profession has yet
learned to appreciate. Not long ago a member of
my department saw a case of paraplegia, probably
due to transverse myelitis from some external
pressure. The spinal fluid was collected and re-
ported negative by one laboratory and by another
that it contained tubercle bacilli. The autopsy re-
vealed a compression myelitis due to a vertebral
metastasis from a hypernephroma. How could
the second laboratory have made such a mistake ?
Easily enough as some of us know? Acid fast
bacilli which sometimes occur in the sediment of
distilled water are not tubercle bacilli, as animal
inoculation would have shown in this case.
Then think of the uncertainty of the \\ asser-
mann reports. We have had a three plus report
from one laboratory and a negative from another
although the two samples were collected from the
same patient in the same syringe and kept in the
same ice box until just before being read.
Further, I believe the same type of antigen was
used. Students of immunolog>' know of these
variations and are always trying to overcome the
treacherous pit falls that beset this valuable test.
They are constantly restandardizing their antigens
and discussing among themselves the respective
merits of the alcoholic and cholesterinized anti-
gens, etc. You should appreciate that there is a
potential element of error in this. An old case of
Tabes dorsalis of mine has a negative serum W as-
sermann by one method and a three plus by an-
other. The laboratory men are ready to object
and cry “It is not the mediod but the man (or
woman) applying it.” Granted! But do we al-
ways know who it is that is deciding for the med-
ical practitioner whether his patient has or has
not active syphilis? I have seen too many men
and women who have been made miserable by the
report of one single positive serum Wassermann
and that in the absence of a characteristic symp-
tomatology of syphilis. Surely a serum Wasser-
mann is of no more value than mucous patches in
the mouth, a characteristic roseola or a general
adenopathy. It should be regarded merely as a
symptom and not as the final and deciding point
of the case. In any event it should be repeated
and if the reports conflict, repeated again and
again. On the other hand do not hesitate to make
a diagnosis of syphilis or para-syphilis even in
the absence of a positive Wassermann, bearing m
mind that it is positive in only 70-80 per cent of
the secondary stage and 60 per cent of the testiary
stages.
Again the Widal or typhoid agglutination test,
though present in 70-80 per cent of typhoid fever
patients does not offer a perfect diagnostic cri-
terion. Normal sera in low dilutions such as
usually jiertains in the dried blood method of the
state board laboratories often completely agglutin-
ate typhoid bacilli. The practitioner should never
forget this and never cease to watch his patient
for rose spots, enlargement of the spleen, the
coated tongue, the dicrotic pulse, the tympanites
and a host of other minor symptoms and signs
with which he used to be familiar before he grew
lazy and waited for some technician one hundred
miles away to tell him (the medical man) whether
his patient has or has not typhoid fever. Shades
of Huxham, Louis and Gerhard, we humbly crave
your pardon I
.And what about diphtheria cultures ? Probably
no laboratory method of diagnosis is more fre-
quently cursed by the good old clinician than is
this. Who has not had negative reports from
state laboratories when clinically it was definitely
diphtheria, and conversely who has not been up-
set by having received a positive report in the
case of a mild angina or a typical follicular ton-
sillitis ? In the former case I always give the
benefit to the clinical picture and give antitoxin,
knowing full well that sooner or later the culture
will be reported positive. Though even this is not
always true as I saw in consultation this year a
case of the most malignant diphtheria in a young
man, from the throat and nose of whom the cul-
tures on four different occasions were reported
negative in two different laboratories. Fortun-
ately the older of the two physicians in charge of
the case had more confidence in his sense of smell
and vision than in the laboratory diagnosis re-
ports and continued to push the antitoxin method
until the disease was overcome, though it required
200,000 units. Now the wise laboratory man can
explain away all these fallacies, I know, but what
I want to drive home is that there are fallacies m
all methods whether of the laboratory or the bed
VoL. XII, No. I]
Journal of Iowa State Medical Society
side, and one method of diagnosis ryust not sup-
plant the other. Each is of value and correlative,
but if either is the superior of the other, it is the
clinical. I can say this having spent two years of
my training in a laboratory and having sur-
rounded myself with all the modern laboratory
methods of diagnosis to which I constantly ap-
peal. When a laboratory assistant tells me that
Mrs. Smith has not got acidosis and I have just
come from her bed side and left her in coma, I
smile and tell him to go down to the ward and
change his mind. Do not think I am a bolshevik
or an iconoclast. Just let me quote my friend
Emerson^®, formerly an assistant in Osier’s clinic
in my time and for three or four years in charge
of Osier’s clinical laboratory and later author of a
text-book on “Clinical Diagnosis.”
“The clinician is the one whose talent is inter-
nal medicine, i. e., the art of clinical inspection
and observation employed in the light of experi-
ence.” “The sciences give him some of his very-
best tools but they are only his tools and not his
art.” “Again the one who takes the history of the
patient and makes the physical examination is the
only one who can interpret correctly a laboratory
finding.” “Exactly identical reports may have
quite different meanings in different cases. He
alone who knows the patient can interpret and
evaluate a specimen under the microscope or in
the test tube and also he often sees that for the
record of which no dotted line is provided on a
laboratory blank but which may suggest further
questions for the history and further physical ex-
aminations.” “The rather widespread and blind
confidence which this past generation has placed
in impersonal laboratory reports has brought in-
ternal medicine into a certain degree of disre-
pute.”
Galant^^ of Switzerland in a recent paper on
psychiatry has pointed out that diagnosis is an
art and cannot be learned out of a book, and that
the practice of medicine is a true art rooted in
insight with diagnosis as the highest achieve-
ment.
The medical journals also contain constant ref-
erence to group practice in medicine. As you will
recall. Dr. C. B. Taylor at our last meeting chose
this topic for the oration in medicine. Here and
there throughout this state as elsewhere in the
country at large are springing up “groups” or
“clinics” made up of specialists, for the most part,
well trained but alas occasionally with no qualifi-
cation for the part assigned them other than “an
overwhelming desire.” Some of these clinics are
foredoomed to failure owing to the improper per-
sonelle, either from character or training. The
far greater danger, as I .see it, lies in the absence
of a competent referee or judge as represented by
the family physician wlio will decide for the poor
patient whether to have his tonsils or teeth or ap-
pendix removed or have a course of radium ther-
apy over the spleen! J. B. Herrick^^ has recently
put it in a more euphenistic manner : “For a phy-
sician merely to announce that in the future he
will limit his practice to a certain kind of di.sease
does not suddenly transform him into a specialist.
Exceptional knowledge or unusual technical skill
are pre-requisities.” Again to quote Herrick,
“What is needed is the analytic mind, the sane
judgment of the wise man of experience.”
“Knowledge comes but wisdom lingers.”
The real fundamental knowledge of the law
is, theoretically at least, possessed by the judge
and not to the same degree by the lawyer of the
prosecution. The latter is too biased, pro or con,
as is too often the surgeon, internist, gy-necologist
or radiologist. The general practitioner formerly
acted as a wise impartial judge. He should do so
still and though it is the hardest of all tasks, it is
still the most noble, even though it is the least
well remunerated. The latter unfortunate side
of the question should be corrected by an educa-
tion of the public, and control of the specialist.
As I feared when I accepted this task I have
been tempted to preach. My excuse is only my
great love and respect for my profession. Com-
ing from an older and more conservative environ-
ment some ten years ago I was struck with the
paradox that in this state one saw a keen, alert
medical profession received rather coolly if not
with suspicion by a rather critical lay-public. The
only explanation that has offered itself as satis-
factory is that the profession as a whole has been
too ready to take up and to over-emphasize the
various laboratory and other diagnostic aids and
to forget the more important historical and clini-
cal findings that had accumulated for centuries.
This has naturally led to wrong diagnoses and
consequently to wrong methods of treatment.
Surely it is time to realize this and to again be-
come common sense clinicians with the delicate
touch, the seeing eye, and deductive mind of our
fathers and to free ourselves from the shackles
of the laboratory technician.
BIBLIOGRAPHY:
1. Claude, H., et de Laulerie, J., Bull. d. i. Soc. Med. d.
Hop. (Par.): 1921: xlv: 36-40.
2. Roger, H., et Blanchard, A., Ibid: 1921, xlv, 40-45.
3. House, S. J., J. Am. M. Assn., Chicago, 1920, Ixxiv, 884-865.
4. Levaditi, C., et Harvier, P., Bull. Acad, de Med. Par.,
1920, Ixxiii, 365.
5. Ottolenghi, D., d’Antona, S., et Tonietti, F., Policlinico,
1920, xxvii, 1075.
G. McIntosh, J., Brit. J. Exper. Path.: 1920, i. 257.
7. Loewe, L., Strauss, I., and Plirschfeld, New York M.
6
Journal of Iowa State Medical Society
[January, 1922
Jour., 1919, ci.'c. 772. Jour. Infect. Dis., Chicago, 1919, xxv,
378-3S3, Jour. Am. M. Assn., Chicago, 1919, lx.xiii, 1056.
8. Thalhimer, W., Arch. Neurol, und Psvchiat., 1921, v.
113-120.
9. Loewe, L., and Strauss, I., J. Am. M. Assn., Chicago,
1920, l.xxiv, 1373-1375.
10. Emerson, C. P., Report of the Committee on Pedagogy of
the Assn. Amer. Med. Colleges, 1921.
11. Galant, S., Schweirerische Med. Wchnschr. Basel, 1921.
li, 87.
12. Herrick, J. B.. J. Am. M. Assn., 1921, Ixxvi, 975-978.
FOCAL IXFECTIOXS OF THE XOSE AXD
THROAT*
PART I SYMPOSIUM ON FOCAL INFECTION
L. W. Dean, !M.D., Iowa City
In almost all cases where the focus of an in-
fection is located in the nose or throat — that focus
is in a paranasal sinus or in lymphoid tissue in the
nasopharynN or the oropharyiiN. In an occa-
sional case this is not true. As it frequently is
verv important to be sure there is no focus m
either of these two localities it is well to mention
briefly certain conditions which only ver\’ rarely
act as foci of infection.
Any ulceration of the mucosa of the nose or
throat is a possible focus of infection. Any con-
dition of the nose which interferes with the pass-
age of the nasal discharge into the nasopharynx
in such a way as to cause a stasis of the fluid in
pockets may cause systemic infection. The nasal
fluid when collected in a pocket in the nose soon
becomes purulent. The mucosa lining the pocket
becomes macerated and ulcerated permitting sys-
temic infection. An atresia of the posterior
nares or a foreign body in the nose may thus pro-
duce pus which is pocketed by the primaiy lesion
and the swollen mucous membrane.
In our service the lymphoid tissue in the naso-
pharynx and oropharynx has been much more
frequently the focus of infection than paranasal
sinus disease. This is true in infants, children,
and in adults. The faucial tonsils are anatomic-
ally well suited to serve as foci of infection. The
tonsillar ciA’pts are sometimes two inches long.
They extend from the surface to the so-called
capsule of the tonsil. Often thev are branched.
They are tubular. Davis^^ estimates that these in-
crease the epithelial surface so that in the aver-
age tonsil it amounts to 25 sq. cm. iMore import-
ant than the increase in the surface is the pe-
culiar shape of these crypts. They may be
crooked. At times their orifices are constructed
so that the crvpts become filled with debris and
even abscesses form in them. As the result of the
infection of the tonsil and the stasis within the
^Presented before the Seventieth Annual Session Iowa State
Medical Society, Des Moines, Iowa, May 11, 12, 13, 1921.
crypt the epithelial cells lining the crypts become
disorganized. The healthy cells prevent the pass-
age of pyogenic organisms from the crypts into
the tonsillar lymphatics. With the disorganiza-
tion of these cells this protective process is lost.
The deep crypts have a tendency to retain infec-
tious matter. This is manifested clinically in the
diphtheria and streptococcic carriers and in the
cases of recurrent tonsillitis and of quinsy.
\\ e should not always conclude that because
the removal of faucial and pharyngeal tonsils re-
sults in an improvement in the systemic condition
that the systemic condition is directly due to the
tonsillar infection and not to a paranasal sinus
disease secondary to the infected tonsils. Es-
jiecially in young children may we question this.
The most common cause of paranasal sinus dis-
ease in children is infection of the pharyngeal and
faucial tonsils. M'e have shown that in 80 per
cent of the chronic paranasal sinus suppurations
in infants and young children that the removal of
the diseased tonsils and adenoids alone results in
a cure of the paranasal sinus disease. Certainly
in all our cases of systemic infection if paranasal
sinus disease was present and not eradicated by
the removal of pharyngeal and tonsillar infections
— the systemic manifestations while improved
have persisted.
The fact that a patient has a systemic infection
and faucial tonsils does not prove that the tonsil
is a focus of infection. A normal tonsil cannot
be a focus of infection because the cells lining the
crypts will not allow the septic organisms to enter
the lymph and blood streams. The presence of
the streptococcus haemolyticus and of white case-
ous masses in the crypts of the tonsils does not
make them dangerous. These conditions may
exist in a perfectly normal tonsil.
Davis- reports finding haemolytic streptococci
in 97 per cent of the tonsils removed from chil-
dren. Alost of these tonsils are removed because
of simple hypertrophy not because of infection of
the tonsil. He also reports the results of .surface
culture of tonsils in normal persons 58 per cent
haemolytic streptococci. In tonsillectomized
throats the hamiolytic streptococci were found in
a very small percentage of cases.
He considers the lymphoid tissue of the naso-
pharynx and oropharynx the normal habitat for
this organism, hence the presence of the haemo-
lytic streptococcus in the throat does not indicate
a diseased condition of the throat. This haemo-
lytic streptococcus does not normally grow in the
nose, and when found present here it always in-
dicates infection.
Bloomfield® carrying on his investigations in
VoL. XII, No. 1]
Journal of Iowa State Medical Society
7
Baltimore found no htemolytic streptococci in
normal throats. He believes that the frequent
presence of this organism in normal throats as
observed by Davis and others indicates the recent
presence of a widespread infection among large
groups of people. Certainly we do not get in
summer the large number of streptococcic throat
cultures that we secure in winter.
Davis considers the bacterial flora of the ton-
sillar crypts to consist of fusiform bacilli strepto-
cocci and spirochetes. Other organisms if intro-
duced into the tonsillar cn-pts rapidly disappear.
Bloomfield^ is of the opinion that organisms
introduced into the throat are removed in two
ways : first, by the mechanical action of fluids ;
secondly, occasionally by the chemical action of
the fluids of the mouth.
A faucial tonsil to serve as a focus of infection
must be diseased. If it is diseased it may serve as
a focus of infection. Even if diseased it is not
necessarily the focus. Two things either of which
if present in a case with diseased tonsils suggest
that at least in part the tonsils are the focus of
infection. A history of sore throat just preceding
the development of the systemic infection or
existing at the time of the beginning of the infec-
tion points very much toward tonsillar focus. A
history of recurrent attacks of sore throat during
which the systemic manifestations are more
marked is of value. Better is to note during the
periods of activity of the systemic manifesta-
tions if there is increased redness of the tonsils
and the region about them. This latter condition
if present is a ver}^ positive indication of the ton-
sil being a focus.
As a faucial tonsil cannot be a focus of infec-
tion unless it is diseased and as a faucial tonsil
should not be removed unless it is diseased it is
very important to know the condition of the
tonsil.
The history of repeated attacks of tonsillitis
and the enlargement of the tonsillar gland at the
angle of the jaw indicate a diseased tonsil. By
inspection and palpation the diseased tonsil can
be diagnosed. A chronically reddened anterior
pillar always indicates a diseased tonsil and is al-
ways present when the tonsil is diseased. The
redness is due to the infection of the surrounding
mucosa from the tonsil. It indicates the infec-
tion is not confined to the tonsil. It disappears
after tonsillectomy. On palpation a diseased ton-
sil feels harder than the normal ; in the depths of
the tonsil one can feel indurated areas which are
areas of infection.
Certain kinds of tonsils are more liable to cause
metastatic infection. The poorer the drainage
from the crypts of the tonsils the greater the tend-
ency to cause systemic disease. Hence tonsils the
orifice of whose crypts have been constricted by
repeated attacks of acute tonsillitis, tonsils whose
crypts have been occluded by incisions or partial
removal, the so-called submerged tonsils many of
whose ciy’pts have their openings occluded by the
overlying anterior and posterior pillars are partic-
ularly liable to cause systemic disturbance. A
tonsil which on palpation reveals a chronic ab-
scess in the bottom of a crypt is a very dangerous
tonsil. The large peduncleated tonsil with the
wide open crypts has good cryptic drainage and
is usually benign.
Because of these deep crypts harboring infec-
tious material the treatment for diseased tonsils is
tonsillectomy not tonsillotomy. A clipped tonsil
as noted by Billings is more liable to be a focus
of infection than an unoperated one because the
scarring of the surface seals the infectious ma-
terial in the bottom of the crypt.
The pharyngeal tonsil when diseased may serve
as a focus of infection. If diseased and capable
of serving as a focus like the faucial tonsil it will
be surrounded by an inflamed area. It is much
more frequently a focus of infection in individ-
uals sixteen years of age or younger than in those
over sixteen. It may, however, be a focus of in-
fection at any age. A very small phar^mgeal ton-
sil if diseased may serve as a focus.
While diseased tonsils and adenoids are the
most common sources of infection of the para-
nasal sinuses we must remember that suppura-
tion of these sinuses may be responsible for the
continued infection of the pharyngeal and faucial
tonsils. We must also remember that infected
faucial tonsils are occasionally secondary to dis-
eased teeth and with the removal of infected teeth
the tonsillar infection may disappear. It is abso-
lutely essential in every case where a diseased
tonsil is suspected to be the focus of infection that
the teeth and paranasal sinuses also be examined.
If infection is found it should be eradicated.
If the infection in the mouth, nose and throat
is confined to the faucial tonsil, the removal of
the faucial tonsils does not permanently eradicate
the focus of infection from the throat. After the
faucial tonsil with its so-called capsule has been
removed there is left behind in the fascia of the
pharyngeal muscles lining the fossa tonsillaris
groups of lymphoid cells. After the removal of
the tonsil these may take on a rapid growth and
soon reproduce a new tonsil which if it becomec
infected may serve as a focus of infection just
the same as the original tonsil. The only way to
prevent recurrence in this manner would be to
8
Journal of Iowa State ]\Iedical Society
[January, 1922
perform a pharyngotomy, that is, remove a por-
tion of the muscles of the pharynx, a procedure
which could not possibly be approved. Fortun-
ately, if these new formed tonsils are removed
again, and perhaps a second time, the tendency to
reproduce disappears and the throat remains clear.
AMien a patient comes into our service with
lymphoid tissue in vault of pharynx, or sinus ton-
sillaris, reporting that the tonsils and adenoids
had been removed by a colleague, we are always
very careful not to give the idea that an incom-
plete operation has been performed. I hope
others will be as charitable when cases we have
operated come to them with apparent tonsil or
adenoid remnants. I have seen a faucial tonsil
grow like a mushroom from the bottom of the
sinus tonsillaris after a clean tonsillectomy be-
fore the wound was healed. I know of one case
of adenoids operated four times by some of the
best laryngologists in America with recurrence.
Faucial tonsils are more often reproduced in
another way. Frequently, in adults, especially
after the removal of the faucial tonsil complete
there will be noticed on the base of the tongue :i
mass of lymphoid tissue. Examination of the re-
moved tonsil shows it intact ; it is surrounded by
a fringe of mucous membrane; the fossa tonsil-
laris is clean. A\'ithin a short time after the oper-
ation, this mass on the base of the tongue may
grow into the fossa tonsillaris, and we have what
appears to be a new tonsil. The removal of the
tonsils produces ofttimes a growth of neighbor-
ing lymphoid tissue frequently spoken of as com-
pensatory hypertrophy of the lymphoid tissue of
the throat.
If we remove thoroughly the pharyngeal and
faucial tonsil immediately following the opera-
tion before there is time for reproduction of
adenoid or tonsil the throat may contain a focus
of infection. There may remain an infected lin-
gual tonsil or infected infratonsillar nodes, or
infected lymphoid masses high up on the posterior
pillar of the fauces. In short, the removal of the
foci of infection from the nasopharynx and oro-
pharjmx is a very painstaking job.
The lingual tonsil is situated on the dorsum of
the tongue just anterior to the epiglottis. It con-
tains crypts and harbors streptococci just as does
the pharyngeal and faucial tonsils. However, its
crj'pts are wide, short and straight^, consequently
it is not commonly the seat of focal infection.
Everj' year in three or four arthritis cases by
work done on the lingual tonsil alone we eradicate
what is apparently the focus of infection. We
have not as yet definitely found this tonsil serv-
ing as a focus of infection in any child twelve
years of age or younger. W e may, however, find
such a case any time. We examine the lingual
tonsils of children when infection persists after
the removal of tonsils and adenoids just the same
as in adults. This tonsil has a tendency to show
the compensatory hypertrophy after the removal
of faucial tonsils and adenoids. It is the lateral
extension of this tonsil which may grow into the
tonsillar fossa and reproduce a new faucial tonsil.
The lingual tonsil may be removed by suspen-
sion laryngoscopy and the use of a broad cautery
tip or the cautery snare. We prefer the former
procedure.
If the lateral extension of the lingual tonsd
should be marked, and is operated upon at the
time of the removal of the faucial tonsil, an ad-
hesion will form between base of tongue and
sinus tonsillaris. This looks bad but I have not
noted that it causes any bad results.
The lymphoid tissue on the posterior surface
of the posterior pillar of the tonsil usually disap-
pears after the removal of the faucial tonsil. Be-
cause of the scarring of the palatopharyngeal
muscle, one of the muscles of speech, if this is
removed, I prefer to leave it alone and watch for
its disappearance after the operation.
The infratonsillar nodes are of greatest import-
ance. They are located on the wall of the
pharynx below the tonsil, or posterior to its in-
ferior pole. These may be adjacent to the fau-
cial tonsil or three-fourths of an inch from it.
They have a capsule similar to that of the faucial
tonsil. Their surface may be covered with the
openings of crypts. These cr}-pts may be deep
and harbor streptococci the same as the faucial
tonsils. They should always be looked for when
the tonsils are removed to eradicate a focus of in-
fection, and if found, should be removed. They
may be removed with tonsillar snare and forceps.
If the work is being done under local anesthesia
this procedure is very disagreeable to the patient.
There is, however, no excuse for leaving a mass
which will continue the infection.
The pharyngeal, faucial, and lingual tonsils are
always present. The infratonsillar nodes and the
nodes on the posterior surface of the pharynx
and posterior pillars of the fauces are very minute
unless they are diseased. When diseased, the in-
fratonsillar nodes may become one-half inch in
width and depth.
The removal of these various masses of lym-
phoid tissue results in the inflammation of the
muscles of deglutition in the throat. The pain on
swallowing is very intense. I trust that I am not
deviating too much from my subject in suggesting
that you can feed your patient liquids, without
VoL. XII, No. 11
Journal of Iowa State Medical Society
'J
pain, by a very simple procedure. Have the pa-
tient sit in a chair with the head tilted backwards.
Apply hands to jaw and neck just below the ears.
Attempt to lift the patient with the hands thus ap-
plied, and while lifting, have him drink. The
fluid will be swallowed without pain.
Many of these diseased tonsillar masses that
are removed prove, on microscopical examination,
to be tuberculous. About 1 per cent of these we
remove are found to be so affected. I know of
no way of positively diagnosing a tuberculous le-
sion of a tonsil before it is removed, unless we
have the ulcerated form which is usually second-
ary to pulmonary tuberculosis.
Infections of the lymphoid tissue in naso-
pharynx and oropharynx is estimated by various
observers as being the focal cause of systemic in-
fections in from 25 to 50 per cent of the cases. ^
Paranasal sinus disease is said to be the focus in
5 to 25 per cent of the cases.
When the focus of infection lies in the para-
nasal sinuses we are confronted by a more diffi-
cult problem. When the infection is in tonsil or
tooth by conscientious work we can remove the
offending member and throw it away. With the
paranasal sinus chronic empyemata the best we
can immediately do is to ventilate, drain, curette,
etc., and hope that by weeks of after treatment
the condition will be eradicated. In the mean-
time, the discharge continues, and while efficient
drainage removes very much the menace it does
not eradicate it.
Putting the figure very small I doubt if 25 per
cent of my cases of chronic suppurative ethmoid-
itis in adults ever get well. During the summer
the discharge ceases. If they go to Asheville,
N^orth Carolina, or Tucson, Arizona, the trouble
may disappear as if by magic. But when our
changeable, damp, Iowa winter weather comes if
they return here or remain here the trouble re-
appears. Dr. Jervey of Gi'eenville, South Caro-
lina, gets 100 per cent of cures in his chronic em-
pyema cases by simple drainage and ventilation.
The prognosis in chronic empyema of the para-
nasal sinuses is influenced more by the patient’s
finances allowing him to seek a favorable climate
than by anything else.
In infants and children with chronic paranasal
sinus disease the story is quite a different one.
As I said before, 80 per cent are eradicated sim-
ply by the removal of diseased lymphoid masses
in the naso and oropharynx. The time to eradi-
cate the chronic paranasal sinus infections is dur-
ing early childhood. In only the very rare cases
is any operative work on nose or paranasal sinus
indicated in a child. Only in the most unusual
severe cases should any turbinate tissue be sacii-
ficed.
The diagnosis and treatment of paranasal sinus
disease is too large a field for us to approach in a
paper of this nature. It is well to remember that
it is difficult to diagnose and to treat, that it when
present cannot always be eliminated. The most
experienced operator cannot feel sure he has
drained every diseased cell in chronic suppurative
ethmoiditis. Paranasal sinuses .serve as foci of
infection in young children the same as in adults.
It is rare to find in a paranasal sinus a focus for
systemic infection in a child under three years of
age. Ethmoidal cells are always present at birth.
The development of the sinuses varies very much.
At the age of five years a child may have a
sphenoidal sinus 18 m.m. in diameter or none at
all. In infants and young children when para-
nasal sinus disease is suspected it is well by means
of an x-ray examination to determine what
sinuses are present, and of those present, what ai'e
of clinical importance on an anatomical basis. A
sinus is of clinical significance on an anatomical
basis when it appears in the x-ray plate as a dis-
tinct cell. Sneezing, nasal discharge, nasal stop-
page, recurrent colds, nasal headaches are symp-
toms of paranasal sinus disease in infants and
young children. The hawking and spitting of a
post nasal discharge, so common in adults, is con-
spicuous by it because of the discharge being
swallowed.
In children with diseased tonsils and adenoids
paranasal sinus disease is very common during
our winter months. It disappears during the
summer. The prognosis of paranasal sinus dis-
ease in infants and young children is very much
better than in adults. Many adults can trace their
incurable paranasal sinus disease back to early
childhood. The time to eradicate paranasal sinus
disease is during its early stages. In children
where we remove tonsils and adenoids for sys-
temic disease we always ask the pediatrist or
orthopedic surgeon to return the patient to us if
the child shows indications of the persistence of
focal infection. It is in this class of cases that a
most careful examination of the paranasal sinuses
reveals, frequently, the presence of paranasal
sinus disease. In short, I think that whenever
you remove diseased tonsils and adenoids from a
child and you do not get the great improvement
that you naturally expect that paranasal sinus dis-
ease should be suspected. If the child still suffers
from nasal discharge and nasal stoppage it is al-
most sure to be present unless you have syphilis
or .some obstructive lesion of the nose.
10
Journal of Iowa State IMedical Society
[January, 1922
REFEREN’CES:
1. Jour. A. M. A., vol. Ixxiv, p. 5.
2. Tonsils and Infections. Jour. A. M. A., vol. Ixxiv, p. 5.
3. Johns Hopkins Bulletin, February, 1921.
4. Johns Hopkins Bulletin, January, 1920.
5. Verger: Illinois Med. Jour., December, 1920.
0. Vtrger: Illinois Medical Journal, December, 1920.
FOCAL INFECTION OF THE IMOUTH,
TEETH, TONSILS, AND MANILLARY
RONES IN RELATION TO SYS-
TEMIC DISEASE*
PART II SYMPOSIUM ON FOCAL INFECTION
Calvin \\'. Harned, M.D., Des ]\Ioines
For many years physicians and other scientific
observers have suspected that systemic infection
often originated from some focal nidus within
the body. Every since the establishment of the
germ theory of disease and the great work done
by Lister and Pasteur over fifty years ago, medi-
cal science has spared no effort in time and labor
in order to more clearly determine the character-
istics of every conceivable form of germ and bac-
terial life.
Thanks to the untiring efforts of scientists and
to the incredible amount of research that they
have carried on, we now know a great deal con-
cerning their origin, life, growth and manner of
culture : Still, a more definite knowledge is neces-
sary, especially in regard to their transformation
and peculiar selectivity for special tissues and or-
gans, before we can speak with authority upon
the subject of focal infection and metastatic dis-
ease, or with certainty of just how and why they
attack certain organs and tissues in certain people
while other tissues and people remain practically
immune against their activities. We know that
systemic disease and infection exist however, and
that it is often the result of small, sometimes
seemingly insignificant foci of infection.
The subject of focal infection, especially as re-
lated to the tonsils, teeth and maxillary bones, has
been so extensively investigated, agitated, ex-
ploited and I might say exaggerated in the last
few years, that it seems unprofitable to attempt
to {iresent, at this time, even a part of the enorm-
ous amount of statistics collected and compiled
by the various investigators. ^Vhile some of the
work is of great importance, much of the data is
only confusing and misleading.
The teeth, tonsils, accesory nasal sinuses and
maxillary bones are very likely to be the seat of
such foci. Eirst, because of their situation at the
entrance of the respiratory and digestive systems
•Presented before the Seventieth Annual Session Towa State
Medical Society, Des Moines, Iowa, May 11, 12, 13, 1921.
and second because their peculiar mechanical and
anatomical construction is such that they may
readily collect, retain and foster the growth of
pathogenic germs.
Miller, of Berlin, was perhaps the first to give
us a scientific discussion of this subject. About
thirty years ago he published a series of articles
in the Dental Cosmos entitled “The Mouth as a
Eoci of Infection.” His material was gathered
from a vast amount of scientific experiments and
observations. However, his conclusions were
that the greatest harm came from the ingestion of
the poisonous excretions that were the product
of inflamed and suppurating tissue, as in pyor-
rhoea, from abscesses discharging into the mouth
and also from decayed teeth.
Later the absorption of toxins and germs into
the blood stream and lymph circulation has
proven to be much more productive of systemic
infection than the simple ingestion of pus. Eor
it is quite probable that at least the greater part
becomes digested and proves harmless.
Eor the last quarter of a centunq diseases of
the mouth, teeth, and maxillary bones have been
looked upon with grave suspicion by both dentists
and physicians when investigating obscure sys-
temic infections. Perhaps in too many instances
we have recommended the removal of all teeth
and tonsillar tissue for the treatment of refractory
cases of neuritis, rheumatism, kidney and di-
gestive derangements.
The trend of both the medical and dental pro-
fessions is toward a more conservative stand on
this subject. There is no doubt in the minds of
many careful thinkers that many unnecessary ton-
sil enucleations have been performed, that thou-
sands of useful and innocent teeth have been
sacrificed, and that at the present time many use-
less curettements of diseased root sockets and so-
called surgical removal of teeth are being done
upon the hazy and unsubstantiated supposition
that possibly they may be the infective foci of
existing iritis, neuritis, rheumatism and heart
affections.
That septic foci do exist in and around the ton-
sils, teeth and tissues of the mouth, even in the
maxillary bones themselves and that at times,
under certain favorable conditions, they do cause
systemic infection, made manifest by one or all
of the above mentioned diseases, I am firmly con-
vinced. But that they are the primary, etiological
factor in as great a majority of cases as some
writers would have us believe, I am greatly in
doubt.
In the first place, many of these reports are
compiled upon a special group of pathological
VoL. XII, No. 1]
Journal of Iowa State Medical Society
II
cases, which would lead us to false theories if fol-
lowed to their ultimate conclusions. For instance,
we would remove the tonsils and all pulpless
teeth in every case of neuritis, rheumatism and
systemic infection of obscure origin.
I am not at all convinced that it is even desir-
able to remove all the sources of systemic infec-
tion from the human body, were such a thing pos-
sible. We know as long as disease exists and
pathogenic germs are present on everj^ hand it is
necessary to develop certain antibodies and to es-
tablish definite immunities in order for the system
to combat and overcome the repeated infections
that are inevitable. If this method of natural
vaccination is necessary, the lymphoid tissue of
the phaiAuix seems to be the most desirable and
suitable point of entrance.
Patients only present themselves to the physi-
cian or specialist for relief when the natural de-
fenses of the body are overcome with an excessive
dose of disease producing germs, or by errors in
the diet, lowering the resistance to such an extent
that germs, which under normal conditions would
be harmless, now become pathogenic and we have
disease produced which is nothing more nor less
than a deficiency disease. In the great majority
of instances it has been from this class of pa-
tients that statistics were made.
Examples of this type are : Rickets, scurvy,
certain eye disturbances, and at the risk of se-
vere criticism I am going to place in this list our
old friend or enemy, pyorrhoea alveolaris. For
experience is rapidly teaching us that mechanical
treatment and diet is the most efficacious method
of treating this condition.
If we are presented with a group of cases suf-
fering with iritis, neuritis, rheumatism, appendi-
citis, gallbladder inflammation, kidney or heart
complications, and careful examinations disclose
the fact that they are also afflicted with pyor-
rhoea, blind abscesses, pulpless teeth, or hypertro-
phied tonsils, it is natural to look upon the latter
as the cause, but it is not at all conclusive evi-
dence. How many people, not patients, have
pulpless teeth without the slightest evidence of
systemic disease or infection? The same cpies-
tion can be asked of each of the above mentioned
conditions. Many people have all these affections
and still remain absolutely free from clinical evi-
dence of other disease. The proportion will prob-
ably be ten, that are otherwise normal, to one
that has systemic infection. Drs. Gilmer, Talboi
and other well known and able investigators have
long contended that a great majority of blind
alveolar abscesses are of hematogenous oidgin.
Their combined opinion and conclusions are far
too valuable to be regarded lightly.
There are many people, on the other hand, who
have iritis, neuritis, rheumatism, heart and kidney
disease in whom no oral foci of infection is
demonstrable. Therefore, it inevitably follows
that it will require some careful study, good judg-
ment and painstaking investigation to separate all
the worthless data from the mass of so-called evi-
dence and statistics that recent investigators have
presented for consideration. That it contains
much valuable information, I am sure. The great
danger lies in our becoming too radical in our en-
thusiasm over the reports we read and a few
cases in which we obtained good results, thereby
becoming careless and over confident in diagnosis
and casting discredit upon the real merits of the
theory of focal infection.
We do not deserve the name of a scientific
body, if teeth and tonsils are to be removed upon
bare suspicion. This is only justifiable in ex-
treme cases in which the necessary delay in order
to examine and eliminate all other possible
sources of infection, would be dangerous to the
life of the patient.
We have at our command sufficient means of
determining if an area of chronic infection exists
in the maxillary bones, soft tissues of the mouth
or pharynx, and when these means fail to dis-
close any pathological conditions we should not
allow a diagnosis of systemic infection from foci
within the mouth to stampede us into rash surgi-
cal procedures.
I admit that a diagnosis of this character on a
given case often places the specialist in an em,-
barrassing position, but if the operation is pei'-
formed it will very likely bring discredit upon the
surgeon and the profession in general.
It might not be out of place to review some of
the methods employed in the examination of the
tissues of the mouth, teeth, maxillary bones and
tonsils, for chronic foci of infection.
One of the first and most important parts of a
thorough examination is a very accurate and com-
plete history.
EXAMINATION OF THE TEETH AND
MAXILLARY BONES
First — Inspection
This is as important as in any other examination
and much may be learned if it is done thoroughly.
A — Examine the entire mucous membrane for dis-
colorations. Changes in contour, swelling. Ulcer-
ations, congestions, fistulous openings. These latter
are usually found on the labial and buccal sides of
the bones, but may be found on the lingual and
palatal surfaces as well.
Second— Palpation
A — By careful palpation you may be able to elicit
tenderness over suspicious areas which will add to
12
Journal of Iowa State Medical Society
[January, 1922
the evidence in favor of bone disease at the apeces
of roots of teeth, or in the maxillary bones them-
selves.
B — Firm, steady, lateral pressure on a diseased
tooth, especially the molars, may disclose pain and
tenderness due to disease not demonstrable by the
x-ray or any other means.
C — Firm, prolonged pressure over a diseased area
in the bone, a blind alveolar abscess or an unerrupted
tooth will usually cause pain.
D — With one finger on either side of the bone to
be examined, producing alternateh' firm pressure
with each finger, will sometimes demonstrate the
presence of bone absorption.
Third — Percussion of the Teeth
The best method is gentle tapping on the teeth
with a small steel instrument, careful comparison^
being made with other teeth, striking the tooth in
such a manner that it will not be driven against its
neighbor thereb}' causing pain in the adjacent tooth.
Change the angle of the blow in all directions and
do not let the patient know which tooth is being
tested. If repeated tests always produce pain when
a certain tooth is percussed it is positive evidence of
pericemental inflammation and perhaps disease at
the apex of that tooth.
F ourth— T ransillumination
The value of this test is only confirmatory, not
positive, and may be very misleading. It is even of
less value in the examination of the teeth and maxil-
lary bones than when used in connection with the
sinuses.
Fifth— Rentgoenograph
I have purposely placed the x-ray last for several
reasons, not that I would deprecate its value, but be-
cause it is very often misleading and may prejudice
the surgeon in arriving at a correct diagnosis. It
tends toward the neglect of an accurate history tak-
ing and predisposes to careless physical examina-
tions.
Too often a diagnosis is made upon the x-ray find-
ings alone, even when taken and interpreted by one
who has no accurate or scientific knowledge of the
possible pathology that may be present in the struc-
ture under examination.
The perfection and almost universal use of the
x-ray has placed in the hands of scores of technitions
who are totall}' untrained in medical science the
means of demonstrating to the patients satisfaction
and ofttimes to the physician and surgeon as well,
conditions that in reality do not exist or that have
little or no influence upon the disease from which
the patient is suffering.
The interpretation of an x-raj- plate or film can
only be made with safety by an expert who under-
stands and is familiar with the physiology, anatomy
and pathological changes that are common and may
be found in the parts to be rayed.
One’s abilitj' will increase as comparisons are made
w'ith the actual findings in the operation room. After
hundreds of such comparisons one might venture to
interpret a radiograph with some assurance, but it is
wise to be guarded for the x-ray is often a treacher-
ous ally. Dark shadows do not always indicate path-
ological bone rarefication, neither does density al-
ways denote abnormal bone formation.
A thorough clinical examination, a painstaking his-
tory of the case, carefully reviewed by physician,
surgeon and dentist all working in harmony is the
wise course in these obscure infections and will often
reverse a diagnosis made upon the x-ray findings
alone.
EXAMIXATIOX OF THE TONSILS
First— Inspection
A — Look for areas of dusky redness along the in-
ner border of the anterior pillars — evidence of in-
flammatory condition. Old scars.
B — Note the physical characteristics of the ton-
sillar tissue. The extent and amount of lymphoid
tissue. The presence of enlarged or congested lin-
gual and pharyngeal tonsils.
C — With a pillar retractor press latterly the an-
terior pillar and expose the tonsil for a more com-
plete inspection.
Second— Palpation
A — Palpate externallj^ for enlarged lymph nodes
at the angle of the jaw. This may be made easier b\
placing one finger inside the mouth pressing the
tissue along the floor of the mouth outward and
downward against the finger on the external surface.
B — -Palpate the tonsil itself with one finger exter-
nal to the mouth forcing the tonsil inward.
Or place one finger on the anterior pillar and the
finger of the opposite hand behind the tonsil, rolling
the tonsil between the fingers. The tonsil is com-
pressed in this manner and the presence of indurated
areas, even small tonsillar abscesses may exist and
be discovered. Normal tonsillar tissue should be of
the same consistency throughout.
The presence of caseous material in the ciA'pts
is not uncommon and is only evidence of previous
inflammation, while a thick creamy or sero-puru-
lent discharge upon pressure is of much more im-
portance and is significant of active infection.
Palpable Ivmph nodes in the drain site of the
tonsil, the presence of indurated masses in the
tonsilar tissue or the reddened border of the an-
terior pillar is sufficient evidence of infection in
the tonsil.
Blood examination may be of value in de-
termining the existence of chronic infection in the
maxillary bones and around the roots of teeth,
for infection there produces a reaction in the
blood giving a leucocytosis similar to infection in
the appendix or elsewhere. (Differential.,'
Blood counts should be made in these obscure
cases. But here again the chance of error is
great, calling for a most intelligent interpretation.
I feel that our attitude toward focal infection
should be open and frank to receive all the evi-
\"0L. XII, No. 1]
Journal of Iowa State Medical Society
13
deuce, both for and against, forming our opinion
and diagnosis only upon the evidence we are able
to demonstrate. When a case is presented we
should be aggressive in our investigations, but de-
mand adequate proof of infection before advising
operation. In this manner we may escape the
humiliating experience of harmful operations, ac-
complish the greatest good for our patients and
promote the best interests of our profession.
GASTROINTESTINAL INFECTIONS*
PART III SYMPOSIUM ON FOCAL INFECTION
M. B. Galloway, M.D., Webster City
The fact of a relationship between abnormal
gastrointestinal conditions and certain focal in-
fections has long been known ; or, rather it has
long been recognized that certain conditions that
we know today to have been focal infections have
and have had an influence upon disturbed func-
tion of the gastrointestinal ti'act. Duke cites Ben-
jamin Rush of colonial days, as making reference
to the fact of improved health, after the removal
of diseased teeth. Rush stated that his work or
observation confirmed those of others of his day.
For many years past, it has been a common ob-
servation of even the laity, that certain people en-
joyed better health after the removal of their dis-
eased teeth, and the substitution of artificial ones.
This was variously attributed to the removal of
the pus and inflammation and to the better masti-
cation of their food. Influences which doubtless
have their effect but perhaps the results were
more largely due to the removal of the chronic
foci of infection. From time to time, certain ob-
servers have noted the effect of foci of infection
upon tissues in other parts of the body. No
definite relation between focal infections and the
gastrointestinal tract was established, until the
work of Rosenow and Billings and their co-work-
ers. The definition of focal infection is given
thus by Billings :
‘‘A systemic or local disease due to infectious
organisms carried in the blood or lymph stream
from a focus of infection. A focus of infection
is a localized or circumscribed area of tissues in-
vaded by microorganisms, and may be either
primary or secondary. By primary is meant the
principal, or first infected areas, from which the
pathologenic agents gain entrance to the blood, or
lymph stream, to cause systemic or organic dis-
ease.”
A focus of infection may be acute or chronic,
‘Presented before the Seventieth Annual Session, Iowa State
Medical Society, Des Moines, Iowa, May 11, 12, 13, 1921.
the former is usually inflammatory; the latter
may be and often is, symptomless.
The causative organisms are most often some
form of the streptococcus ; others have been
found to be the cause of focal infection, such as
the pneumococcus and some few others.
The portions of the gastrointestinal tract most
often affected by focal infection are; Appendix,
gall-bladder, stomach and duodenum. Less often
apparently, pancreas, colon, sigmoid and rectum.
Some of these may be regarded as the location of
primary foci for les.ions in other parts of the
body.
In ulcer of the stomach and duodenum, Billings
states that in experimental animals the lesion is
produced by a streptococic embolic infection of
the submucosa of the stomach with resulting
small hemorrhages into the surrounding tissues.
In consequence of the hemorrhage and the
presence of the infectious microorganisms in the
surrounding tissues, anemic necrosis so weakens
the overlying mucous membrane, that it becomes
digested by the gastric juice. If the infection is
virulent enough and there is sufficient injury,
chronic ulcer results. They maintain that ulcer
results, because of a circumscribed area of tissue
losing its normal resistance, through malnutrition
or neurosis, or to the gastric juice becoming di-
gested.
Burge and Burge assert, that decreased resist-
ance of a circumscribed area of the stomach, to
gastric juice, due to a decreased oxidative process
of the cells of the area, followed by a subsequent
digestion of the area by pepsin, is the explanation
of ulcer.
However, Rosenow states “These observations
still leave the cause of the local disturbance un-
explained.” Rosenow’s experiments indicate, that
local malnutrition, described by Bertram, and the
circumscribed area of decreased oxidation, de-
scribed by Burge and Burge, are commonly due to
embolic localization of streptococci having a
chemotatic attraction, or affinity for the mucous
membrane of the stomach.
Rosenow’s work upon ulcer has been verified
by Heemholz, Hardt and others. A number of
workers have failed to confirm the results that
Rosenow has obtained. We believe, however,
that the burden of proof remains upon them.
As Rosenow himself says, “The inability to ob-
tain evidence of the localizing power of the bac-
teria in the hands of some workers, as pointed
out by Gay, might well be explained by insuffi-
cient attention to details.
Many of the Eastern writers do not accept the
theory of focal infection in its etiologic relation
14
Journal of Iowa State aIedical Society
[January, 1922
to ulcer. Willenski however, in speaking of ulcer
states: “A certain number of them are due to
primary infections by bacteria,” and goes on to
say that the reliability of the work of Rosenow
and others showing that the portals of entry are
frequently the teeth and tonsil, and that a selec-
tive localization of these bacteria occurs in the
stomach, has not yet been finnh' established. He
admits, however, that there have been recurrences
in the course of a medical cure of ulcer, which
followed a fresh attack of tonsillitis, or the re-
appearance of pyorrhoea about the teeth and states
further, “That many of our patients as we see
them clinically, exhibit a most deplorable condi-
tion of the teeth.”
Carroll of Xew York, says “Rosenow’s work
may not be conclusive, but it will require many
years of concentrated effort on the part of scien-
tific workers to disprove it.”
Sippy accepts the theor}* of the etiologic rela-
tion of focal infections to ulcer of the stomach
and duodenum, and gives a very gnarded prog-
nosis in all ulcer cases, where he is not certain
that all foci of infection have been removed.
Langstroth, working at the University of Cali-
fornia, found foci of infection in 84 per cent of
all ulcer cases. Y’hile his total number of cases
is small, it is suggestive. Our own observations
confirm these results. The following case is a
typical one :
C. G. C. Merchant, aged fortj-six, ulcer of ten years
standing with hyperchloridria, pyloraspasm, vomit-
ing, pain of the usual ulcer type, occult blood in
stomach contents and stools, filling defect with the
barium meal. Numerous attempts at cure failed even
under the most favorable conditions. A chronic
alveolar abscess was discovered and he admitted that
he had known of this for years. This focus of in-
fection was thoroughly eradicated and the diet and
treatment allayed all symptoms. There has been no
return in four years, though he has been upon a
liberal diet.
In ulcer, teeth and tonsils are oftenest the
primary focus of infection. Prostare is entitled
to dishonorable mention and likewise, the lower
bowel. Frontal and maxillary sinuses and the
chronic appendix may be mentioned.
Hempelman states that the appendix is a fruit-
ful source of trouble in ulcer, and urges the rou-
tine removal of the appendix when operating for
stomach ulcer. ]\Iost of us know that the chronic
appendix and ulcer are frequently present in the
same patient, and that the removal of the ap-
pendix frequently clears up ulcer symptoms.
Soper urges the routine examination of the
lower bowel for foci of infection in vilcer cases.
In children, ^^'etherill has been convinced of
the etiologic relation of tonsillitis to chronic ap-
pendicitis.
Parker says that cyclic vomiting in children is
usually relieved by the removal of infected ton-
sils and adenoids. Other writers mention the im-
proved health of children following the removal
of foci of infection, though they do not specifi-
cally mention the gastrointestinal tract.
Adrian, cited by Billings, states that the his-
tologic lymphoid structure of the tonsil and ap-
pendix is similar and this similarity of tissue is
given as a reason for the etiological relationship.
He speaks of such cases of appendicitis as
“Anginal Appendicitis.”
Connell believes that the genitourinary system,
and especially the urinary bladder, is the seat of
the primary focus in many cases of appendicitis.
All cases of appendicitis are probably not focal
in origin, many acute cases are doubtless due to
direct infection by coli. It must be remembered
that in all focal infections, that there may be
more than one focus of infection, that is keeping
the chronic condition alive.
The appendix has been held to be the primary
focus in many causes of ulcer of the stomach and
duodenum, cholecystitis and even tonsillitis. The
frequency with which it is found coexistant with
ulcer and gall-bladder disease is certainly sug-
gestive. There is no doubt that in many cases
where chronic appendicitis and ulcer of the stom-
ach were co-existant, the patient has been oper-
ated for the appendicitis, the removal of the ap-
pendix as a primary focus and the restricted diet
following the operation, have been sufficient to
affect a relief of the symptoms, and in time, as
a cure of the ulcer.
Cholecystitis is unquestionably due at times to
a hematogenous infection with strains of strepto-
cocci and possibly to other organisms. A patient
suffering from acute cholecystitis was operate*'
upon, and it was noted that in the fundus of the
gall-bladder there was a small softened area
which was excised.
From the softened tissues, Rosenow isolated a
strain of streptococci which when injected into
animals produced cholecystitis. This patient suf-
fered from tonsillitis and a short time before the
onset of the attack of cholecystitis, had suffered
from an acute attack of tonsillitis. Strains of
streptococci isolated from the tonsils had a like
affinity for the gall-bladder in intervenously in-
oculated animals. Clinically, Lansgtroth found
chronic foci of infection in 100 per cent of gal'-
hladder infections.
It has been stated that chronic cholecystitis has
VoL. XII, No. 1]
Journal of Iowa State ]\Iedical Society
15
been improved, and at times practically cured, by
the eradication of a maxillary sinusitis.
Our own experience confirms the results ob-
tained by the various workers quoted.
Bibliography
Billings, Frank: Wise. Med. Jour. v. xiii, p. 257, 1914
Billings, Frank: Lane Medical Lectures, 1917.
Blackwell, K. S.: A'a. Med. Monthly, v. xlvi, p. 501, 1920.
Carroll, John: Personal communication to the writer, 1919.
Connell, F. G. : Wise. Med. Jour. v. xviii, p. 157, 1919.
Hartzell, T. D. : Journal-Lancet, vol. xxxviii, 1919.
Hempelman, L. H.: Jour. Miss. Med. Ass’n. v. xv, p. 202,
1918.
Langstroth, L.: Am. Jour. Med. Sc. vol. civ, p. 232, 1918.
Livermore, W. II.: Jour. Okla. State Med. Ass’n. v. xvii,
p. 326.
Parker, E. H.: Journal-Lancet, vol. xxxix, 1919.
Rosenow, E. C. : Surg., Gynec. and Obst. v. xx, p. 403, 1915.
Rosenow, E. C. : Journal of Dental Research, v. i. No. 3, 1920.
Sippy, Bertram, W.: Personal communication to writer, 1917.
Willenski: Am. Jour. Med. Sc. v. cliv. No. 3, 1920.
Wetherill, H. G. : Jour, of the A. M. A. v. Ixv, p. 666, 1915.
FOCAL INFECTION IN THE GENITO-
URINARY TRACT*
PART IV SYMPOSIUM ON FOCAL INFECTION
John S. McAtee, M.D., Council Bluffs
Focal infection from a genitourinary stand-
point should properly be divided into two groups.
1. The cases in which the primary focus lies
in the genitourinary tract.
2. The cases in which the focus lies elsewhere,
the genitourinary tract being secondarily in-
volved.
While we must consider infections of the kid-
ney under the first group, it is generally conceded
that in pyelitis, pyonephrosis, and other lesions of
the upper urinary tract, metastases are rare,
though there is commonly a coexisting severe
toxemia. The ureter, bladder, prostate, vesicles,
etc., may be affected as a result of the kidney
focus, but this is generally not of hematogenous
origin, as the infection is most frequently borne
by the urine or is a so-callcd descending infection.
The possibility of metastases, the result of a
cystitis is rather far fetched and in all jirobability
does not occur. The bladder is not an absorbing
organ, and according to Magonn^, absorption uf
bacteria through the normal bladder mucosa, or
the acute inflamed mucosa must be relatively
slight if it occurs at all. Infections of the bladder
may occur when there is pathology in the prostate
or urethra sufficient to interfere with drainage.
It has been demonstrated by injecting pure cul-
tures of bacteria into the bladder of animals that
no infection of the bladder resulted when drain-
age was not interfered with. It was found how-
*Presented before the Seventieth Annual Session, Iowa State
Medical Society, Des Moines, Iowa, May 11, 12, 13, 1921.
ever, that when the penis was ligated after the
injection of the bacteria that cystitis immediately
ensued. In bladder infection due to obstruction,
toxemic symptoms are frequently noted, but here
as in kidney infection there is a scarcity of re-
ports of actual metastatic localization.
The prostate and vesicles are probably the most
frequent site of focal infection situated in the
genitourinary tract and the most prolific cause of
systemic disturbance. The location of the pros-
tate lays it particularly liable to infection from
kidney, bladder, urethra, and rectum, to specific
infection, to lowered vitality as a result of too
active or too passive sexual existence, to injury,
and to disturbances in circulation which would
contribute to infection. A large majority of in-
dividuals contract gonorrhea and are subjected to
many kinds of treatment. It is reasonable to as-
sume that a small percentage of these are cured.
The greater percentage however, are left with a
permanently damaged urethra and should they
overcome the gonorrheal infection, they are par-
ticularly vulnerable to invasion by some of the
more chronic organisms of lesser virulence.
We think it is pretty generally conceded that
focal infection in one part of the economy may
cause serious disturbances in another part or af-
fect the body as a whole, and granting that a
gonorrheal infection situated in the posterior
urethra and prostate can cause an arthritis, endo-
carditis, etc., etc., is there any reason to argue
that other organisms cannot cause a disturbance
of equal degree or as much at least as the focus
situated in a tonsil or a sinus. We think the
answer depends entirely on the drainage of the
part. If drainage is good, there is little or no
absorption of pathologic material, if drainage is
poor or lacking we will have absorption in a
greater or lesser degree. It is a fortunate fact
that drainage of the genitourinar}- tract is usually
good. There are conditions however, which se-
riously interfere and probably the most common
of these is strictme of the urethra. Fibrosis, the
result of inflammation of the prostatic gland and
ducts of the seminal vesicles are also factors
which largely contribute to poor drainage, and to
absorption, and Peters-, in reporting ca.ses of
non-specific arthritis from genitourinary origin
arrives at these conclusions when he says, “The
pathological findings in this class of cases are
usually ;
1. A non-specific infection of the prostate and
seminal vesicles.
2. Inflammatory fibrosis of their ducts near the
urethral opening.
3. Extension of the infection to the posterior
urethra arid bladder.
16
Journal of Iowa State Medical Society
[January, 1922
4. Partial stricture of the urethra, materially dis-
turbing drainage.”
In the event of infection in the posterior
urethra, prostate, or vesicles, with partially inter-
rupted drainage, we have all of the contributing
factors to the establishment of a focus that may
later cause metastases elsewhere in the body, and
we agree with J. T. Geraghty^, that the seminal
vesicles ai'e much more commonly the cause of
persistent bacillar)" and coccal infection of the
urine than is generally supposed — the fixing of
the responsibility on the seminal vesicles as the
source of continued or recurrent infection is not
always easy. In many cases the presence of
vesiculitis may readily be determined by palpa-
tion, but it is surprising what a large percentage
of infectious active foci are present in one or the
other vesicles and still careful palpation may re-
veal few changes.
Occasionally interesting cases will be seen com-
plaining of persistent arthritis usually most evi-
dent in the lower extremities which health re-
sorts, arch supports, and the removal of teeth and
tonsils do not benefit or relieve, but examination
of the prostate and seminal vesicles reveal the in-
volvement of these structures and with suitable
treatment, namely massage, irrigation, and vac-
cine the arthritis clears up promptly.
Xo .search for the primary site of a focal in-
fection should omit a thorough examination of
the genitourinary tract, and while we agree that
the palpation of the prostate and vesicles is a dis-
agreeable procedure, at the same time we contend
that it is pregnant with possibilities and not too
disagreeable to do any good. AMiile it is not our
intention to compare the urinan," tract with other
portions of the body as a site of focal infection,
we maintain that it should not be overlooked in an
examination.
Under the second group, we find diseases of
the urinary tract that are caused by foci situated
in the teeth, tonsils, sinuses, etc. Considerable
time could be taken up in dealing with any one of
these subjects, but I wish merely to lightly touch
upon each. Xephritis, kidney abscess, stone,
pyelitis, ureteral stricture, cystitis, prostatitis,
vesiculitis, and urethritis are not infrequently the
result of focal infection. Hematogenous infec-
tion of the kidney or pelvis is a less common form
than the ascending infection, but it has been
shown during recent years to occur with greater
frequency than was at one time supposed. It is
found in infants, children, and adults, and prob-
ably occurs more frequently in infants and chil-
dren, and tonsils, furuncles, or carbuncles, teeth
or sinuses are many times the seat of the primar)"
foci. It is now recognized that bacteria are con-
stantly entering the lymphatics from the intestines
and other sources. They may be destroyed at the
point of entry or at the lymphatic glands, or they
may pass through the lymphatics into the blood
stream. One of the functions of the renal
parenchyma, especially the convoluted tubules, is
to remove bacteria present in the systemic circula-
tion. It has been proved that the virulence of
these bacteria is not reduced in their passage
through the body. The excretion of bacteria m
this way does not give rise to any symptoms which
show that the kidneys are damaged. WT know,
however as a result of experiments on animals
that the secreting membrane is injured by the
passage of bacteria. The damage is probably
slight and is repaired partly or completely by the
regenerative powers of the kidneys. In some
cases long continued excretion of bacteria or their
toxins may be the cause of interstitial changes in
the kidneys. It is held that the excretion of bac-
teria does not cause pyelonephritis unless some
additional factor is present. Predisposing causes
of pyelonephritis are traumatism, excessive func-
tional activity, the elimination of toxic bodies,
previous disease of the kidney, such as urinary
obstruction, calculus or new growth. It is ex-
ceptional however, to find any of these factors
present, and it is more likely that chronic toxemia
from chronic constipation, or an excessive dose
of an exceptionally virulent strain of bacteria, as
a result of acute systemic infection, or focal in-
fection elsewhere in the body are the decisive
factors. Peters^, in discussing acute unilateral
kidney infection of hematogenous origin, says,
“A small embolus detached from some focal in-
fection as tonsils, fui'uncles, abscesses, or rheu-
matic infection is carried by the blood stream di-
rectly to the kidney substance. Associated with
the embolus are a few microorganisms, which
lodged in the capillar)- vessels of the glomerulus,
set up a focus of the disease which spreads
throughout the kidney by way of the tubules, and
lymph spaces,” which demonstrates we believe,
that he arrived at practically the same conclu-
sions.
Ureteral stricture or narrowing of the ureteral
lumen due to intrinsic inflammatory changes in
the ureteral wall, is a disease far more common
and of vastly greater importance than our pre-
vious experience has lead us to believe and that
it may be the result of a focal infection elsewhere
in the body is the theory of no less an authority
than G. L. Hunner^, who makes this statement,
“Experience has taught us that we should expect
stricture in any patient complaining of obscure
VOL.XII, No. 1]
Journal of Iowa State Medical Society
17
abdominal symptoms particularly in tlie lower ab-
domen and accompanied by pain in the hips and
thighs. In addition, we usually find that the pa-
tient has a history or shows evidence of tonsil-
litis, sinusitis, or bad teeth.” And he again says
when discussing intractable bladder symptoms
due to ureteritis®, “My experience with ureteral
stricture leaves no room for doubt as to the focal
infection theory answering for the vast majority
of these cases.”
Now his conclusions have been arrived at
through the study of one hundred cases of ure-
teral stricture, and a number of cases of bladder
ulcer and cystitis. They can, without question, in
many instances be charged up against a focus
elsewhere. No doubt, in the male, they are de-
pendent in a degree on the condition of the pros-
tate and whether or not stricture of the urethra
exists, both tending to interfere with proper
drainage.
The bladder may be infected from the kidney,
the bacteria being borne by the urine. The kid-
ney may or may not participate in the inflamma-
tion and the bacteria may be blood born. Cases
of cystitis and extreme bladder distress may also
occur with urethritis, in which the gonococcus
can be ruled out, and these cases show little or no
improvement under the usual forms of treatment
although they clear up readily enough when dis-
eased tonsils, or other foci are removed.
In bladder ulcer, and particularly in the type
described by Hunner, careful history taking and
a thorough search will frequently lead to the find-
ing of diseased teeth, tonsils, adenoids, or sinuses.
Metastases may also occur in the prostate and
vesicles though they are probably more frequently
involved from ascending urethritis.
Urethritis may be due to hematogenous infec-
tions and the result of the usual forms of treat-
ment afford little or no relief. The removal of
the offending focus being necessary as is demon-
strated by the following cases.
Case No. 1. R. T. B., age twenty-five, male, sin-
gle. Consulted us on October 13, 1919, complaining
of a slight muco-purulent urethral discharge, and
burning on urination. He had first noticed dis-
charge following prophylaxis while in the army on
Novemer 19, 1918. Examination made of the dis-
charge at that time was negative to the gonococcus.
He had never had gonorrhea. The examination of
the prostate and vesicles were negative. Smears
made from urethral discharge were negative to the
gonococcus but showed a few epithelial cells and an
occasional pus cell. There were also present gram
positive diplococci that did not have the character-
istic morphology of gonococci. Examination of the
urine showed a few staphylococci. Urethroscopy re-
vealed an intensely granular, red and sensitive ure-
thra. For about six weeks this patient was treated
with silver nitrate solution and with no apparent
good results. He was then put on a zinc sulphate
solution and had been on this for about two weeks
with scarcely any improvement, when he came in
complaining of a sore throat at the same time saying
that his burning on urination and discharge were
worse. The examination of the throat showed a
tonsillitis and he had a temperature of 102. He was
referred to a throat specialist who later removed his
tonsils. Urethral treatments were stopped at this
time. We did not see the patient again until four
months later when he came in to tell us that his old
trouble had all left him. He did not have any dis-
charge, there was no burning on urination, and ure-
throscopy showed a normal urethra.
Case No. 2. J. C. W., age thirty-eight, married.
Came to us on June 20, 1920, complaining of a con-
stant sharp pain which seemed to be located at the
meatus, a frequent desire to urinate, and a so-called
“morning drop.” Duration three months. He had
had gonorrhea sixteen years ago. Was married ten
years ago and has four healthy children. His wife’s
health is and has always been excellent. Smears and
cultures made from the discharge and the prostatic
expression were negative to the gonococcus but
showed some gram positive diplococci and a few
staphylococci. The prostate and vesicles were neg-
ative. Cystoscopy negative. Urethroscopy showed
a red granular urethra that was hyper-sensitive. On
quizing the patient about his past health, he hap-
pened to remember that he had lately had several
attacks that he called rheumatism in his shoulders.
This led us to send him to a throat specialist who re-
ported, strange to relate, that he could find no path-
ology in his tonsils or sinuses. On examination of
his teeth however, we found that he had pyorrhea.
An x-ray of the teeth showed three root abscesses..
He was referred to a dentist who treated his teethi
and extracted the ones with abscessed roots. Acting-
on the supposition that the urethritis was due to the
focus in the mouth, the urethra was not treated and
the patient was told to go home and to report back
to us in two months. On October 10, he came in.
His symptoms had rapidly cleared up. There was
now no pain, no frequency, and urethroscopy showed
only a very slight redness on the posterior half of
the anterior urethra. We saw this patient again in
January of this year and he said he was in perfect
health. No examination was made of the urethra at
this time as he would not permit it, saying that he
was perfectly well and saw no reason for it.
These are a few of a number of cases that
could be cited to maintain that focal infection is
apt to be just as responsible for metastases in the
urinary tract as in any other portion of the body.
For a number of years, urologists have come
more and more to recognize the fact that the
genitourinary tract is just as subject to serious
and acute sequelie during or following tonsillitis
18
Journal of Iowa State Medical Society
[January, 1922
as is the heart, the joints, or other portions of the
economy.
W’e have purposely avoided mentioning the
complications of tuberculosis or gonorrhea under
either of these heads, because pages could be
written on these subjects and then merely scratch
the surface.
Conclusion
1. Cases of metastases where the primary^
focus is situated in the genitourinary tract are
usually due to diseased prostate and vesicles.
They can be cured by appropriate treatment of
the offending members namely, massage, irriga-
tion and vaccines.
2. Metastases in the genitourinary tract, the
result of a focus in teeth, tonsils, sinuses, etc.,
will show great improvement almost immediately
upon the treatment or removal of the distant
focus.
references
1. Absorption from Urinary Bladder into the Blood Stream.
J. S. Magonn, Jr., Iowa State Medical Journal, 1921, No. 4,
page 146.
2. Non-specific Arthritis from Genito-urinary Infection. C.
K. Peters, Journal of the Maine Medical .\ssociation, August,
1918.
3. Seminal Vesicle Infection. J. T. Geraghty, Johns Hopkins
Bulletin.
4. Acute Unilateral Kidney Infections of Hematogenous
Origin. C. N. Peters, Journal of the Maine Medical .\ssociation.
June, 1917.
5. Ureteral Stricture — Report of 100 Cases._ G. L. Hunner,
Johns Hopkins Hospital Bulletin, Vol. xxix. No. 323, January,
1918.
6. Intractable Bladder Symptoms due to .Arthritis. G. L.
Hunner, Journal of Urology, Vol. iv. No. 6, December, 1920.
Discussion of Symposium on Focal Infection
Dr. Clarence E. Van Epps, Iowa City — The wide-
spread vogue of the theory of focal infection has a
very logical background. great many infections
are focal in origin, .\mong others we may mention
tuberculosis, syphilis and septicemia. It is not to
such infections, however, that the theory applies, but
rather to those systemic infections of a similar type
of which chronic arthritis may be taken as an exam-
ple. Again, if the focus causes active local sj'mptoms
and the systemic effects are ver\^ acute, one rarely
thinks of it as a focal infection, as in the case of
acute rheumatic fever preceded by an acute sore
throat. The term applies typically to those condi-
tions in which the focus gives rise to few or no
local symptoms. The differences of opinion have
arisen not in regard to those cases with an active
focus and systemic infection, but in the milder type.
The logical background for the theory is furnished
by the fact that an arthritis is to be viewed not as
a primary malady, but as due to an infection else-
where. Another factor is the e.xistence of infected
tissue especiall}’’ about the head. Dr. Dean states
that 60 per cent of adult tonsils are diseased. By this
it is not meant that they are merely contaminated
by bacteria, but that they show histologic changes as
a result of infection. A'gain, a definite relation has
often been noted between acute tonsillitis and an
arthritis. With these facts in mind, it is logical to
consider the tonsil as a focus in many of the milder
arthritides. Failure of removal of diseased tonsils to
relieve the arthritis does not disprove the etiological
relationship. This may be explained by the existence
of secondary foci or by the fact that the bacteria
transplanted to the joint are leading an independent
existence. How much can be promised from treat-
ment of a primary focus must depend upon statis-
tics rather than upon theory. Dr. Dean finds that
60 per cent of tonsils are diseased. Dr. Steindler
finds that 1 per cent of the population has or has had
arthritis. Evidently, only a small fraction of diseased
tonsils cause arthritis. Again, Dr. Steindler finds
that only 3 to 5 per cent of arthritis cases are in
some degree associated with evident focal infection,
and that in only ten to twelve cases has treatment
of the focus given definite improvement. These sta-
tistics make us conservative as to promising too
much or as to urging radical treatment of foci. We
have all noted an occasional striking benefit from
treatment of a focus, but we have also observed very
many failures. This is not a criticism of the theory
as to etiologj’, but it is from the viewpoint of radical
treatment. Onlj’ when the tonsil is definitely dis-
eased as shown by increased densitj^, reddened an-
terior pillar and enlarged subangular gland, and
when clinically a sore throat has been definitely re-
lated to joint symptoms, may relief by radical treai-
ment be reasonably hoped for. What has been said
in regard to tonsils holds with much greater truth
regarding the teeth. Dental sepsis is said by Dr.
Fenton to exist in 80 per cent of people over twenty
years of age. Evidently It rarely causes arthritis.
Another criterion is the fact that professional men
with dental sepsis only rarely have radical treatmen’'
even in the presence of active systemic symptoms.
Radical treatment in the absence of local subjective
symptoms and the presence of merely indefinite
systemic symptoms is certainly to be deprecated.
Gonorrheal infection of the genito-urinary tract may
cause systemic symptoms. It is far from settled that
active treatment of the focus is helpful. Regarding
the relation of gall-bladder and appendiceal infection
to systemic disease, we have little to say. We have
personally never observed such a relation nor do our
friends the surgeons observe such a sequence.
Throughout, I have used arthritis as the typical sys-
temic symptom. Among others to be mentioned are
endocarditis, myocarditis, gastric ulcer, cholecystitis,
appendicitis, nephritis, and periodic vomiting of chil-
dren. Sedgwick Schloss and Byfield report that a
large percentage of the last condition is cured by the
removal of tonsils and adenoids. I would conclude
that in cases of systemic infection of which arthritis
may be taken as the best example, every effort should
be made to find a primary focus. If such a focus
is found in a definitely active condition, and a definite
sequential relation can be established, radical trea*^-
ment is advisable. If contrary conditions prevail, a
conservative attitude should be adopted.
VoL. XII, No. 1]
Journal of Iowa State Medical Society
19
Dr. Walter L. Bierring, Des Moines — The ques-
tion of focal infection in its relation to chronic
arthritis or to the different forms of neuritis and
myositis, is still the most prominent in every clinical
discussion of the subject. It seems to me that the
statistics furnished us by Pemberton in the observa-
tion of something over 400 cases of arthritis at U. S.
Army Hospital No. 9 at Lakewood, New Jersey, per-
mit of drawing perhaps the best conclusions; this
work was carried on under excellent facilities for ob-
servation in a hospital under military control and
with the help of the very best laboratory assistants
in determining sugar tolerance, creatin elimination
and other metabolism studies, as well as accurate
bacteriological investigation in close cooperation with
the chiefs of the several clinical services. He is of
the opinion that in the majority of instances a focu.-
of infection is the essential cause of arthritis, and
that of the different foci, the dental foci, and the
foci about the upper air passages, were the more
prominent, although in some instances he gave
nearly equal prominence to foci in the gastro-intes-
tinal and urinary tracts. In the general treatment of
chronic arthritis, the mistake is often made in relying
too much on the removal of the suspected focus of
infection. That should necessarily be the first
thought, but it should be remembered that this is
only eliminating the original cause, and the patient is
by no means relieved of the arthritis or in any sense
cured, without further systematic care. Arthritic pa-
tients present a definite type in that they have to be
regarded individually, requiring a plan of treatment
that should consider every feature of the patient’s
condition. I wish that more emphasis had been
placed on the relation between focal infection and
endocarditis. I believe there is no question but that
in endocarditis we have a definite systemic expression
of focal infection. Furthermore, that there is a much
closer relationship between systemic diseases, par-
ticularly heart disease, and gall-bladder infection,
than has been emphasized here today. I am sure
that with a low grade of infection and absorption of
infective toxic matter from a diseased gall-bladder
the myocardium gradually becomes impaired, and by
the time consent is obtained for removal of the gall-
bladder or of the focus in the same, the myocardium
has been so damaged that the result is far from
satisfactory. And it seems to me that in the various
degenerative processes that take place in later life,
particularly of the circulatory system, there is noth-
ing so etiologically important as the infective foci
that are allowed to remain for a long period of time.
I am still unable to say anything definite about the
removal of so-called devitalized teeth. It seems to
be an open question whether the simple removal of a
devitalized tooth is really very helpful in the elimin-
ation of systemic infection. It is true that a reaction
frequently occurs after removal of the teeth^ and the
affected joint will ache for twenty-four hours after-
wards, but that is no criterion of specific systemic
relationship. The simple absorption of blood fibrin
would be sufficient to bring about the systemic or
local reaction. Therefore I am in full accord with
the spirit of conservatism that was urged so strongly
by Dr. Harned in regard to the promiscuous extrac-
tion of teeth.
Dr. Arthur Steindler, Iowa City — It is about 100
years since Benjamin Rush first called attention to
the relation between tonsillar disease and joint dis-
ease, and, if I am not mistaken, it is about twelve
years since Dr. Billings first published the results of
his study of the relation between chronic arthritis
and the tonsil. .Although a few }'ears afterwards he
became more pessimistic about it, this study is still
going on, and I hope it will be continued, because it
has certainly furnished us with something tangible
and definite. All the speakers tonight agree that
definite information is to be had, the only question
being to what extent. I must say this in regard to
treatment of joint conditions. I think the term, cur-
ing a chronic arthritis, should be avoided, because it
is pathologically impossible to cure a joint, already
changed and diseased, by the removal of a primary
focus which has been responsible for these changes.
On this fact hinges the question as to whether local
treatment of the affected joint is dispensable or in-
dispensable. I never saw a joint that could be led
to the point of the best possible recovery without
local treatment. It is, of course, clear that the re-
moval of a focus will save a joint from exacerbation^,
and I believe all those engaged in the study of focal
infection will concede that the work of eliminating a
focus of infection means that the joint will from that
time go on to recovery through the forces of nature
aided by local treatment. In my opinion, it is prepos-
terous to depend on the removal of the focus alone
and to deprive such a joint of the advantages of im-
mobilization. For instance, we have seen joints that
are in a state of remission, apparently recovered, after
a focus of infection has been removed, and in which
apparently the focus of infection had some bearing
on the condition of the joint; but we see those joints
relapse by virtue of the neglect of local treatment.
These joints are never in position to be functionally
over-strained, and still the condition of the joint has
come to a sort of biological equilibrium. Nobody
would think of neglecting treatment of a tuberculous
knee just because the patient has evidently overcome
his pulmonary tuberculosis. Nobody would dream
of allowing a tuberculous knee which shows signs of
activity to go unresected just because that patient
has no active pulmonary tuberculosis. And in this
respect I can detect no difference in the treatment
of chronic conditions of the joint due to a primary
focus of infection. Whether the removal of the focus
is of influence upon the exacerbation of the inflam-
matory condition of the joint or not, no treatment is
adequate which does not give due consideration to
the local condition of the joint. And here is the
danger we incur by putting our trust in the removal
of the focus, which, even if it were in closest causal
connection with the joint, would never lead to a
biological cure of the condition of the joint if other
pathological postulates in the joint are neglected.
20
Journal of Iowa State Medical Society
[January, 1922
So I wish to make the point very strong that no
amount of evidence in favor of focal infection of a
given joint will ever eliminate the necessitj^ of local
treatment for this joint.
Dr. Frank M. Fuller, Keokuk — I just want to inject
a little remark here to get the history of medicine
straight. I understood one of the essajdsts to say
that about thirty years ago Dr. Aliller of Berlin first
called attention to the relation of the teeth to sys-
temic infection. I happen to have in my possession
one of the very first Iowa medical journals, pub-
lished in my own home town of Keokuk, and in this
first number of the first journal published west of
the ilississippi river in 1850 is an article on “The
Effect of the Teeth on General Conditions,” in which
the author states that the condition of the teeth may
affect not only the alveoli, but every organ of the
body and even life itself. And I am only sorry that
I did not bring that copy here, because, strange as
it may seem, in the year 1850 an article was published
in that journal which could have been read on this
floor today with practically everything in it that has
been said in regard to the effect of diseased teeth in
bringing about S3'Stemic conditions. I merelj' pre-
sent this item just to show that many of the things
that we consider modern are of considerable age.
The author probably had a prevision of some of the
conditions that exist today, but the article, having
been published in an obscure journal,. has passed out
of the knowledge of medicine. I merely arise to
enter this as a part of the history in this study of
medicine.
Dr. Dean — Before leaving the subject I would like
to say a few words about w’hat I consider to be the
difficultj- of eradicating the foci of infection about
the nose and throat. So far as the lymphoid masses
in the nasophar\mx are concerned, I think I made
clear in my paper perhaps some of the difficulties
involved. In discussing this subject Dr. Steindler
used an expression which vmu possibly did not no-
tice, namely: That if the focus of infection could be
eradicated, then such and such a thing might happen.
Now, I suspect that Dr. Steindler made that state-
ment because of the numerous cases wdiich he refers
to me for the examination and elimination of foci
of infection which might be related to the s>^stemic
condition, and which exist in the nose, the naso-
pharj'nx or the oral pharjmx. Ever}^ case which Dr.
Steindler sends to us in our service for such reason
is taken care of to the best of our abilitj', and is re-
turned to Dr. Steindler with the request that if for
any reason he suspects that the foci of infection
have not been eradicated he will return the patient
to our service. And a surprisingly large number of
these cases do come back to our service, and when
they return we find the faucial tonsils out clean, the
pharyngeal tonsjl gone, the lingual tonsil perhaps re-
moved, but still there is a redness of the pharynx,
and this redness comes and goes, and anj'body who
looked at the throat would know that there is left
somewhere in that neighborhood, infection. When
it comes to the question of paranasal sinus disease.
I do not think it is within the bounds of possibility in
every case Avherein the paranasal sinus disease has
served as a point of focal infection, for the condition
to be eradicated and the patient remain in this
climate. I know that there are in my service manj-
cases with chronic suppuration of the sinuses in
which the paranasal sinus disease cannot be eradi-
cated as long as the patient resides in Iowa. We get
rid of suppurative discharge from one paranasal sinus
or another, and we may try and convince ourselves
that we have a good result, but the patient comes
back in a few months, in the fall or spring, with the
same trouble present. I do not believe that in the
State of Iowa we will, with the best surgical and
medicinal treatment, succeed in eradicating 60 per
cent of the chronic cases of suppurative ethmoiditis,
and of all the paranasal sinuses the ethmoidal sinus
is the one which serves most frequently as a focus
of infection.
Dr. Harned — Dr. Bierring stated that systemic in-
fection does not alwaj's clear up on removal of the
foci. That is very true. Dr. Steindler emphasized
the fact when he stated that knee joints that had
once been infected required the assistance of local
treatment. In connection with this statement I wish
to mention a point in regard to the removal of teeth.
In many instances we find a great number of ab-
scessed and decayed teeth associated with gum dis-
eases, inflammation associated with pyorrhea, and
gingivitis, and the patient in a very critical state. He
may have joint disturbances, heart lesions, and kin-
dred derangements. If in these cases we remove all
of the teeth at one sitting, if there should be ten,
twelve or fifteen, we are very likely to make that pa-
tient much worse, for we have thereby thrown into
the sj'stem and overloaded it with an excess of patho-
genic microorganisms and protein matter that may
be absorbed from the wound, which certainly makes
the condition worse and may in some instances even
prove fatal, especially in cardiac conditions. We
should remove these sources of infection gradually
and carefull}^ In certain cases in which joints are
affected, and especially if diseased teeth are present,
we will procure far better results by removing a por-
tion of the infective foci at a time. The joint be-
comes worse for three or four days, we have an
exacerbation of the local condition, which, however,
soon clears up and ultimately becomes a little better
than it was at first. If we then inject into the sys-
tem another vaccination by removing two or three
teeth, with a limited curettage perhaps of the bone,
we have another exacerbation and the patient again
becomes worse, but never quite as bad as he was at
first, and his recovery’ this time is more rapid than
it was following the first operation. If we carry
out this process slowly we will get the best result in
the long standing arthritic cases. I agree, however,
that we should have local treatment in addition even
though the local focus should be removed. There is
another point I would like to mention. In a few re-
ferred cases I have noticed that the teeth and in-
fections around about the teeth are more particularly
VoL. XII, No. 1]
Journal of Iowa State Medical Society
21
identified with iritis, neuritis and other nerve le-
sions, than are the tonsils or the paranasal sinuses.
I do not know why this is, but it has been brought to
my attention in quite a few cases, and I would ask
if any one else has noticed that neuritis and iritis arc
more particularly asociated with diseases in and
around the teeth than those of the tonsils and para-
nasal sinuses, while the tonsils are more particularly
associated with muscular rheumatism and myositis.
At least this has been my experience. Just a word
about Miller of Berlin, who, as far as I can learn,
was the first man to give us a systematic study il-
lustrated by a large group of experiments and cases
along the line of focal infection originating within
the mouth. His articles were of great value, es-
pecially to the dentist, and they opened the way to
a broader understanding of the subject by both the
medical and the dental profession. It may be, how-
ever, that many men had thought about it and had
written papers on the subject.
Dr. McAtee — In my paper I failed to mention
vasotomy in connection with treating the seminal
vesicles. I think about 80 per cent of cases, in which
there is an involvement of the seminal vesicles, are
cured by massage, irrigation, and vaccine; the other
20 per cent certainly are cured by vasotomy and the
injection of a 5 per cent collargol solution. Vasicu-
lectomy is I think seldom indicated because vasotomy
will take care of those cases that do not respond to
massage and vaccine. In regard to iritis, it was for-
merly the opinion that gonorrhea might produce
metastases in the eye. Of late years however urolo-
gists have come to the conclusion that iritis seldom
occurs as a result of metastases in the genitourinary
tract if it occurs at all.
AMERICAN SOCIETY FOR THE CON-
TROL OF CANCER
25 West 45th Street, Xew York City
Statement made by Dr. Harvey R. Gaylord, one of the Di-
rectors of this Society and Director of the State Institute for the
Study of Malignant Disease, Buffalo, Xew York.
The people of the State of New York will want
to receive a statement on the stewardship of the
purchase of 2j4 grams of radium for which
$225,000 was appropriated by the state, and an-
nouncement of which was made by Governor
Smith a few days ago.
I am very glad to take this opportunity both in
the name of the Institute for the Study of Malig-
nant Disease, the State and the American Society
for the Control of Cancer which supported this
purchase to say these words :
The experiment in state ownership of a thera-
peutic agent, as exemplified in the purchase of
this radium for social utility will have a far-
reaching effect. This is a development of state
medicine to which no one can object and Gov-
ernor Smith deserves the thanks of the state for
what he did.
Any citizen of the United States may avail
himself gratuitously after October 15th of treat-
ment with the 2j4 grams valued at $225,000 re-
cently purchased by New York State and the
first gram of which was delivered by the Radio
Chemical Corporation of X"ew York last week.
Preference, however, will be given to citizens of
New York State.
The first gram is now in the vaults of the In-
stitute at Buffalo and the appliances necessary
for its use in the treatment of cancer are now in
course of construction. The engagement of a
competent physicist to work with this radium is
also announced. The radium we are using is an
American product, mined in Colorado, brought
2900 miles across the continent in the form of 125
tons of carnotite ore to the extraction plant ai
Orange, N. J., where it was reduced by frac-
tional crystallization to its present state.
The first purchase of radium by any state
marks a step in the health activities of an Ameri-
can commonwealth. Up to the present we have
had no therapeutic agents, so expensive that they
could not be afforded by the average practitioner.
In the case of radium that condition arises. The
unit for efficient use costs not less than $12,000
and represents 100 milligrams. A gram is worth
$120,000. The greater the quantity in an installa-
tion the more efficient it is, and the less it costs
per treatment. New York State has met this con-
dition by purchasing an amount available for all
its citizens.
The value of radium has already arrived at a
stage where states, and if necessary the govern-
ment, should make radium available for cancer
treatment, gratuitously and beyond the realm of
financial limitations. The advent of radium as a
therapeutic measure is the most important for-
ward step in the treatment of cancer.
It is not surprising that when radium first
made its appearance over-optimistic claims for its
use and hope of its utility should have occurred.
But that time is now past. Radium has been
made available in smaller and larger amounts to
all of the important centers of cancer research in
this country, with the result that not alone has
new knowledge of this agent been greatly ad-
vanced but the technique of its use as well as its
limitations have been more definitely defined.
The last six years have marked steady progress m
its application, and means of more scientifically
and more efficaciously employing it have been
developed.
The state institute as a result of carefully con-
22
Journal of Iowa State Medical Society
[January, 1922
trolled scientific experiment in its hospital felt
that the time had come when the State of New
\ ork should logically provide an adequate
amount of radium for the institute on the basis
that its value is so definitely demonstrared that it
should be made available without cosi to the citi-
zens of the state and that the opportunities for
research should now be extended along practical
lines. The state institute has had since 1914 an
amount of radium sufficient for scientific study.
Private philanthropy has given the Alemorial
Hospital in New York City a large amount of
radium for scientific investigation and practical
application for the past four years. The Cancer
Research Commission of Harvard University has
also had an adequate working supply. The ad-
vances made in these and other quarters has
steadily strengthened the confidence in the use of
this agent and all of these centers are now seeking
means to increase their supply.
The State of New York which in 1898 took the
lead by founding the first modern state cancer
research institute in this country should properly
be made the first state to appropriate the neces-
sary funds for the purchase of a sufficient
amount of radium for the use of its citizens hav-
ing available for this purpose a center of cancer
knowledge and fully equipped scientific research
laboratories where its use can be made imme-
diately effective, and from which scientific prog-
ress can be confidently anticipated.
The usefulness of radium in the treatment of
neoplasms is still in its infancy, but there are al-
ready certain kinds of cancer in which its use of-
fers advantages and the results obtained are an
improvement upon any means we have hereto-
fore possessed. It must, however, be remembered
that our main reliance in the treatment of cancer
is surgery but radium in combination with sur-
gery, frequently greatly improves the prospective
cure.
The scientific development of the last two
years in the use of radium, largely through the
work of Professor William Duane of Harvard
University, made available a means of using ra-
dium which has immensely strengthened its use-
fulness. This method is the use of the emanation
of radium in place of the application of radium it-
self. This method is only available when you
have at least one gram.
Cancer today is one of the most important dis-
eases in the United States. It increases 2S pe’’
cent every ten years. In the United States 90,000
deaths occur yearly from it, being of equal im-
portance to tuberculosis. In New York State
about 8000 deaths occur yearly.
The purchase of the radium has other signifi-
cance than merely its use for the treatment of
cancer. It gives an opportunity for research and
its use under scientific conditions is sure to in-
crease our knowledge of cancer. While surgery-
still remains our main reliance in the fight against
cancer we can only hope greatly to improve the
results of surgery by bringing the patient to sur-
gical treatment at the earliest possible moment.
This can only be accomplished by the diffusion of
knowledge among the laity of the first beginning-^
of cancer. It is with such work as this, that the
Society for the Control of Cancer has particularly
charged itself. It is felt by the society that the
advent of an alternative will overcome the re-
luctance of many cases to present themselves to
their physicians. The society represents 900 phy-
sicians and laymen and looks with great interest
at the purchase and congratulates New York
upon the step it has taken.
The purchase of this radium by an American
commonwealth from an American company
which has mined its ore in the State of Colorado,
will bring still further to the fore the pre-emin-
ence of America in the treatment of cancer. Buf-
falo will become a radium center. While Europe,
through Madam Curie, first made the precious
element known to the world, the United States
has developed both the ore, its extraction and its
use as a therapeutic agent. It is today in the fore-
front of treatment of cancer. This purchase may
have a tremendous effect upon further progress
in this direction.
PHYSICIANS WHO LOCATED IN IOWA
IN THE PERIOD BETWEEN 1850
AND 1860
D. S. Eairchild, M.D., P.A.C.S., Clinton
Dr. Wm. S. Robertson
Dr. Wm. S. Robertson of Muscatine was for
many years one of the most interesting figures in
Iowa medicine. He came to Iowa when the state
was young and developed a vigorous manhood
which together with a sense of honor gave him an
influence and leadership which continued through
a long and useful life. Dr. Robertson was full of
physical, moral, and intellectual courage, sound
judgment and skill in directing the means of
treatment as known in his day.
His work was replete with opinions of Euro-
pean medical men and as a student of letters he
was a diversified reader as he read Latin and
Greek as well as he did English. The only liter-
VOL.XII, No. 1]
Journal of Iowa State Medical Society
23
Dr. Wm. S. Robertson
24
Journal of Iowa State Medical Society
[January, 1922
ature now open to him in medicine was from the
German but this he got through the Lancet which
was and is one of the greatest medical reservoirs.
Dr. Robertson possessed a cheerful and op-
timistic spirit which fitted him for the trials and
difficulties confronting the pioneer. He possessed
an unusual personal magnetism and with a fine
physical organization he became easily a leader
and a worthy successor of his distinguished
father, Dr. J. !M. Robertson.
Dr. Robertson’s sense of public duty led him
ver}- early in life to advocate a public health ser-
vice in Iowa and probably to him more than any
other was due the legislative enactments creating
the Iowa State Board of Health of which he was
the first president.
When Dr. Robertson first came forward with
a plan for a Public Health Service but little
thought had been given to the subject, and he
was met everywhere with an indifference which
cannot at the present day be fully appreciated, but
his courage, his earnestness and devotion at last
prevailed, and a beginning was made in a line of
service which will stand foremost in the medical
activities of future years. In this struggle, the
experience Dr. Robertson had gained as a state
senator, and the influence he had acquired in pub-
lic life, was of great advantage.
Dr. M'. S. Robertson was born June 5, 1831 in
Georgetown, Pennsylvania. When a boy his
father. Dr. J. ]\I. Robertson, moved to Burlington,
then the most important city of the southwestern
section of Iowa. His preliminar}- education was
obtained in the public schools of that day, later
he matriculated in Knox College, Illinois, but be-
fore completing his course his health became im-
paired and he was obliged to abandon his college
course. In 1852, Dr. Robertson entered his
father’s office as a medical student. In 1854, he
attended his first course of lectures at Jefferson
Medical College, Philadelphia, from which he
graduated March 8, 1856.
In the meantime, and even before he began the
study of medicine, his father moved from Burl-
ington to Columbus City. Immediately after re-
ceiving his diploma Dr. Robertson entered upon
the practice of medicine with his father, which
continued until the breaking out of the Civil M’ar.
It is to be said of Dr. W. S. Robertson that his
interests and activities extended beyond the rou-
tine of the practice of medicine, as was true of
many of our earlier practitioners. He was more
than a practicing physician and surgeon ; he was
active in all that related to civil life, he was the
type of the man of his generation who was able
to meet every condition with understanding, firm-
ness, and courage. During the early days of
practice, the conditions in a new country de-
manded a readiness to meet dangers and exposure
unknown to men of this day. Beside the risk of
medical practice, the country was infested with
outlaws, particularly horse thieves. In certain
sections along the Mississippi, they were ex-
tremely active. The personal exploits related of
Dr. Robertson in hunting these pests of civiliza-
tion and bringing them to justice, read like the
frontier stories that filled our youthful imagina-
tion.
In 1858-9, Dr. Robertson joined a military com-
pany and devoted considerable time to the study
of military science, which prepared him for great
usefulness in the days near at hand. With the
breaking out of the Civil War, there was pressing
need of men of courage, resolution and knowledge
to lead our soldiers. Dr. Robertson’s training
and character fitted him for this service, and on
July 13, 1861, he was mustered in as major in the
Fifth Iowa Infantry. This regiment did guard
duty until called into active service at the battle
of Xew Madrid, IMarch 4, 1862. Major Robert-
son was honorably mentioned by his commanding
officer on this occasion in his official report.
After two years active service. Major Robert-
son resigned (July 23, 1863) and resumed prac-
tice at Columbus City. In 1869 after a wunter of
graduate study in Xew York, he moved to Mus-
catine.
When the medical department of the Iowa
State State University was organized at Iowa
City, Dr. Robertson was elected chief of the de-
partment of the theory and practice of medicine,
which position he held to the time of his death,
January 20, 1887.
For many years he was a leading member of
the Iowa State jMedical Society, of which he be-
came a member in 1861, and was elected president
in 1873. During his many years of service as a
member of the State Medical Society and as a
professor in the state university, the doctor gained
a body of friends who mourned his loss in a most
affectionate manner. The writer recalls the ses-
sion of the state medical society at Sioux City the
year next following his death when a special
meeting was called to participate in a memorial
tribute of affection and regard.
In 1873 while acting as county physician. Dr.
Robertson gave his attention to the sad condition
of the feebleminded children being cared for in
the County Poor Farm. Upon visiting other
counties he found similar conditions existed. This
caused him to bring the matter before the Iowa
State Medical Society. He was appointed chair-
man of a committee to present this subject to the
state legislature with the effect that he drafted a
VOL.XII, No. 1]
Journal of Iowa State Medical Society
25
Dr. Sumner B. Chase
26
Journal of Iowa State Medical Society
[January, 1922
bill “Plea for the Feebleminded Children of the
State of Iowa.” This resulted in the state institu-
tion which now is housing 1000 patients at Glen-
wood.
Dr. W. S. Robertson died at iMuscatine, Iowa,
January 20, 1887.
Dr. Sumner B. Chase
Dr. S. B. Chase was born in Limington, York
county, Blaine. October 4, 1821 and died in
Osage, Iowa, June 19, 1891.
Dr. Chase was one of the number of strong
earnest men who laid the foundation of a medical
practice in Iowa in the decade between 1850 and
1860; at a time when men of character and phy-
sical energy- were needed.
Dr. Chase was born of sturdy New England
stock ; of a generation of farmers. When five
years of age, he made his home in Scarboro,
availing himself of such opportunities for an edu-
cation as came in his way. The young man hav-
ing decided on medicine as his life work, entered
the office of Dr. Seth Larrabee, a well known
practitioner, as a student and in May, 1849, grad-
uated from the medical department of Bowdoin
College. He first located in practice at Portland,
iMaine. Six 3-ears later, or in September, 1855,
Dr. Chase came to Iowa and located in Decorah,
but a }ear later moved to Osage where he prac-
ticed thirt}--five )-ears or until his death in 1891.
The field of usefulness for a trained ph}-sician
in a thinl}- settled communit}- as was Osage at
that time, and among people who knew but little
of sickness, extended be}mnd the administration
of medicine, to public service activities, and in
1856, Dr. Chase was appointed postmaster. la
August of the same 3'ear, he resigned to accept
the office of register of deeds, of the United
States Land Office, then located in Osage.
Dr. Chase was a democrat in politics and m
1884 was elected a delegate to the National Dem-
ocratic Convention which nominated Grover
Cleveland for president. Politics, however, was
secondarv and incidental in his career, and was
regarded as a dut}-. His interest in the profes-
sion of medicine was shown when in 1854, he
was a delegate from !Maine to the American IMed-
ical Association at St. Louis.
In 1873, Dr. Chase became a member of the
Iowa State IMedical Societr- and in 1881 wa'
elected its president.
Dr. Chase was a kindl}- man and an ideal fam-
ih' phr'sician. His high character and sr-mpa-
thetic nature brought him a large following of
friends and patients. He was a deeply religiou,s
man, a free-will Baptist from choice — but a Con-
gregationalist from affiliation. He married iMiss
Almira B. Cobb of Limington, iMaine. Three
sons and two daughters were born to them. One
son became a well known ph}-sician and a pro-
fessor in the m.edical department of the Iowa
State Lmiversity.
Y’e are permitted to utilize in this connection
a short biographical sketch of his son, Charles
Sumner Chase, which appeared in the Iowa
Alumnus for October, 1920.
Dr. C. S. Chase
Dr. C. S. Chase, who retires from the headship
of the department of materia medica and phar-
macolog}-, began his connection with the Univer-
sit)- of Iowa in 1892, succeeding Dr. P. J. Farn.“-
DR. C. S. CII.A.SE
worth. Up to now these two men have been the
onl)- occupants of this chair since the establish.-
ment of the College of Medicine in 1870.
.\lthough Maine is Dr. Chase’s native state, he
has spent most of his life in Iowa. He received
the B.S. degree in engineering from Ames Agri-
cultural College in 1874 and was a student in the
department of medicine at the Umversit}- m
1880-81, previous to his graduation from Rush
[Medical College in 1882. In 1895 the UniversiUc
of Iowa granted him an honorary degree of mas-
ter of arts.
For nearh- twent}--five years Dr. Chase prac-
ticed medicine in Waterloo; fifteen A-ears of th'S
period was coincident with part-time work at the
universitv in non-residence. Later he moved with
his famih' to Iowa Cit}-.
Dr. Chase continues his instruction in the ccl-
VoL. XII, No. 11
Journal of Iowa State Medical Society
27
leges of dentistry, and pharmacy, and the nurses’
training school : but expects to find time to com-
plete a history of the College of Medicine of the
University of Iowa covering its first fifty years.
He plans to retire from all the colleges with which
he has been associated since 1892 — June of 1922,
thereby completing three full decades of service.
He has not at the date of this article definitely
decided as to his plans for the future, but may
possibly re-engage in general practice for a few
years in the City of Waterloo, where he spent so
many years of his life most happily.
DR. F. C. MAHLER
A complimentary dinner was given Dr. F. C.
Mahler of New London by the physicians of
southeastern Iowa on the attainment of sixty
years active practice. Dr. Mahler has for many
years held a high place in the profession of
southeastern Iowa. He represents the highest
DR. F. C. MAHLER
type as a physician, and as a man. Through
these many years. Dr. Mahler has ministered to
the sick in a most unselfish manner, and in early
days the exposure and hardships were beyond
the understanding of the present generation of
physicians. The generous spirit of his medical
friends and associates is to be commended in rec-
ognizing the merits of the man who has stood
as an example of stability, modesty, and un-
selfish devotion to service.
Through the courtesy of Dr. C. A. Boice, we
are able to present a cut of Dr. Mahler whose
face has become familiar to those attending med-
ical societies, particularly the Iowa State Medical
Society, and we may cherish the hope that his
strength may be conserved for many more annual
sessions.
THE NATIONAL HEALTH EXPOSITION
The National Health Exposition, occupying 60,000
square feet of floor space, will be held in the Jeffer-
son County Armory at Louisville, February 1-9, 1922.
This is under the auspices of the United States
Public Health Service, State Board of Health of
Kentuckv, Jefferson County Board of Health and
the Health Department of the City of Louisville. It
will include exhibits in hospitalization, nursing,
dentistry, medicine and pharmacy. The University
of Louisville, the public school system, and various
local, state and national health organizations will
participate.
The annual conference of the city and county
health officers, the annual convention of the Ken-
tucky State Public Health Association and other
health meetings are already scheduled in connection
with the exposition.
An institute will be conducted by the United
States Public Health Service and its program will
include :
Dr. M. J. Rosenau, dean of the Harvard School of
Public Health; Dr. Josephine Baker, director of the
department of child hygiene. New York City Board
of Health; Dr. Wm. A. Evans, former health officer
of Chicago and the most distinguished public health
editor in America; George T. Palmer, president of
the Illinois Tuberculosis Association and director of
the Bureau of Tuberculosis of the Illinois State
Board of Health; Dr. Frederick R, Greene, secretary
of the council on health and public instruction, Amer-
ican Medical Association; Dr. Valeria H. Parker,
director of the Interdepartmental Board of Social
Hygiene; Dr. John H. Stokes, distinguished syphilo-
grapher of the Mayo Clinic; Dr. Frankwood Will-
iams, director of the National Association of Mental
Hygiene; Dr. W. S. Rankin, state health officer of
North Carolina, a member of the council of health
and public instruction of the American Medical As-
sociation and recently president of the American
Public Health Association; Dr. John Dill Robertson,
health officer of Chicago; Dr. John R. McDowell, di-
rector of health for the Lake Division, American
Red Cross; Dr. John R. McMullen, United States
Public Health Service, and Miss Frances Brink, di-
rector of the National Organization for Public
Health Nursing.
Expenses will be paid through the sale of commer-
cial exhibit space to a limited number of reputable
firms.
28
Journal of Iowa State Medical Society
[January, 1922
Sffurnal of tfje
3obja ^tate JMctiltal ^ocietp
D. S. Fairchild, Editor.... ....Clinton, Iowa
Publication Committee
D. S. Fairchild Clinton, Iowa
W. L. Bierrinc Des Moines, Iowa
Howard Iowa City, Iowa
Trustees
J. W. CoKENOwER Des Moines, Iowa
T. E. Powers Clarinda, Iowa
W. B. Small Waterloo, Iowa
SUBSCRIPTION $2.75 PER YEAR
Books for review and society notes, to Dr. D. S.
Fairchild, Clinton. 'All applications and contracts
for advertising to Dr. T. B. Throckmorton, Des
Moines.
Office of Publication, Des Moines, Iowa
Vol. XII January 15, 1922 No. 1
THE PREVENTION OF PUERPERAL
INFECTION
In England and in the E'nited States, the medi-
cal press is presenting many strong papers in sup-
port of measures to lessen the excessive mortality
from childbirth. It appears to be generally ac-
cepted that obstetric medicine has in the last
twenty or thirty years made less progress than
other branches. This as it appears to the writer,
is due largely, to the conditions under which ob-
stetric medicine is carried on. The Report of the
Registrar-General for England and Wales for
1919 showed that of the deaths assigned to preg-
nancy and childbirth, 3,204, in number, 1,208 or
37 per cent were due to puerperal infection. In
1913 when the per cent of infection was 32, Sir
Arthur Xewsholm declared that “such infection
should be as rare in obstetrics as it has become in
surgery.”
M’hile sepsis is the largest individual factor in
deaths from childbirth, there are other, mostly
preventable accidents. As observed by the Brit-
ish Medical Journal, puerperal septicemia is al-
most entirely due to the faulty technique and un-
preparedness when the doctor and the nurse come
into association with the woman during the first
few hours of her labor.
The proper technique is well enough under-
stood by our general practitioners, but it cannot
be carried out in the home service. It frequently
happens that the practitioner has had no oppor-
tunity to make an examination until called when
the woman is in labor, and in his efforts to learn
something about his case is liable to infect her,
nothing is ready, perhaps a trained nurse cannot
be secured, altogether the case does not materially
differ from an emergency accident case. As long
as obstetric practice is conducted in this manner,
the sacrifice of mothers must go on. The remedy
is the construction of community hospitals when
aseptic midwifery" is possible. In cities, where
church or other hospitals exist, community func-
tions can be assumed with community aid. Yerj'
few of our people need charity assistance, but do
need the benefit of a small fee, both medical and
hospital, even below the actual cost. Generally
this can be secured, but in some of our society
hospitals the conditions on entrance discourage
some of our less fortunate patients.
If by education and personal influence, the
maternity hospital idea could be brought into
general operation, an examination and record
made, and if need be, a treatment instituted, that
would obviate some of the preventable accidents
of the puerperal state, and, when labor super-
vened the principles of aseptic surgery could be
employed, the sad and distressing experiences of
puerperal septicemia obviated. How long must it
be that valuable lives must be sacrificed to save
a few dollars in taxes?
^Malpractice suits are showing an increased ac-
tivity. Lhifortunately, too many are difficult to
defend. It is clearly apparent that the public are
holding the profession to a more strict account-
ability, and are drawing their own conclusions,
aided perhaps by unfriendly competitors. A word
of caution should be given to those who are in-
stalling modern x-ray apparatus. It is being
pointed out by the lay press that the modern x-ray
is so powerful, that extraordinary precautions are
necessar}- to prevent serious burning of patients,
and the courts are holding that an x-ray operator
is a highly trained professional technician, and if
a physician cannot qualify as an x-ray expert, an
accident may be evidence of presumptive negli-
gence.
The increasing difficulties in defending mal-
practice cases should be a warning to give early
notice of a threatened suit, or notice of suit.
Recently, we had a case in point, a physician noti-
fied Mr. Butcher that a suit against him was set
for only two or three days from the date of mess-
age. It so happened that IMr. Butcher had a case
for the same day so Mr. Butcher wired that
doctor to ask his attorney to secure a continuance
and he would take up his case. IMr. Butcher not-
ified the committee of the facts, and the commit-
VoL. XII, No. 1]
Journal of Iowa State Medical Society
29
tee communicated at once with the doctor, ex-
plaining' the situation, and as the doctor was in
good standing in the society offering to take up
his case under the rules (inclosing a copy of the
rules). Malpractice suits involves so much to
the defendant that it is difficult to understand
the indifference of certain members of the pro-
fession to their own interests.
We have made the rules so simple, and so easy
to observe, that there is no good reason why the
defendant physician may not at once communi-
cate either with the committee, or our attorney,
so that we may set the machinery of defense in
motion, and to keep us informed of all the cir-
cumstances of the case. It is not only to the in-
terests of defendant, but also to the profession at
large.
We have published the rules from time to time
in the State Journal, and are here publishing the
rules adopted by the defense committee in ac-
cordance with the by-laws of the State Society,
for the protection of the fund created to defend
physicians sued for malpractice.
RULES GOVERNING THE MEMBERS OF THE
IOWA STATE MEDICAL SOCIETY WITH
REFERENCE TO THE DEFENSE FUND
1. The object and purpose of maintaining a de-
fense fund is not to aid in defeating any just claim
which any person may have against any member of
this Society for malpractice. The Society recognizes
that sometimes mistakes may occur with the most
careful and skillful physicians and surgeons, and the
Society, through its committee, will use all just and
honorable means to bring about a fair settlement of
any such cases. The necessity of maintaining such
fund arises out of the fact that nine-tenths of the
suits brought against doctors for alleged malpractice
are little less than blackmail. Experience shows that
the great majority of such cases are brought without
any purpose of prosecuting them to judgment, but
only with the view of forcing the doctor to settle
rather than to go to the expense and publicity of a
trial.
Every member of the Society is interested in such
litigation, because every dollar that is paid upon
unjust claims in settlement thereof is encouragement
for further attempts to extort money by such meth-
ods. In the organization of the defense fund it is the
purpose of the Society to aid its members in defend-
ing against these attempts at extortion. The ex-
pense of making a proper defense is a burden to
many members of the Society, and inasmuch as all
are interested in defeating unjust claims, it is no
more than just that all members should contribute
to aid in such defense.
2. It is not intended that the benefits of the de-
fense fund shall be available for the purpose of aid-
ing in controversies over bills for services, and in
case an action is brought by a doctor to recover for
his services and the defendant simply sets up a coun-
terclaim to the extent of the bill or for the purpose
of defeating the bill, asking no affirmative judgment
beyond the amount of the bill, such doctors shall not
be entitled to the benefits of the defense fund.
Where, however, an action is commenced upon a bill
and a counter-claim is filed for malpractice, or an
independent action is filed for malpractice in which
the patient claims a judgment against the doctor in
excess of the amount of the bill, then in such case
the doctor is entitled to the benefits of the defense
fund the same as if no action had been brought by
him.
3. Experience shows that many malpractice suits
arise out of a controversy over bills for services.
For this reason it is the judgment of the committee
that in all cases where there is any serious contro-
versy about a bill for service the doctor ought to
submit the matter to the attorneys for the associa-
tion before commencing suit upon the bill. The pur-
pose of such submission is not that they shall render
any service toward the collection of the bill, but that
from experience in such matters they may make
suggestions with reference thereto which may avoid
litigation and prevent the commencement of an ac-
tion for malpractice.
4. Whenever an action is commenced or threat-
ened, the doctor should write to the committee on
medical defense, making a full, fair statement of the
facts so that they may advise the doctor at as early
a time as possible with reference to the action or the
threatened action. In many cases advice may be
given which will avoid litigation.
5. In all cases where a notice is served upon a
meinber of the Society of a suit or contemplated
suit, the same should be sent forthwith to the at-
torneys for the Society, in order that no disadvantage
may result from delay.
6. Members will understand that in the com-
mencement of any action in the district court a notice
is served at least ten (10) days before the term for
which suit is brought, and that gives plenty of time
to communicate with the attorneys for the Society so
that rights may be fully protected.
7. In connection with any notice so sent to the
attorneys or committee, the members should send at
the earliest possible date a full statement of the facts
pertaining to the case to the committee, who will
communicate with the attorneys as to the course of
action to be taken in this particular case.
8. While in most cases which actually come to
trial it will be necessary to have local counsel to co-
operate with the attorneys for the Society, such local
counsel should not be employed until after com-
municating with the committee or attorneys for the
Society. In many instances the cases will be dis-
missed or otherwise disposed of without trial, so
that the expense of local counsel may be avoided.
9. It is of the utmost importance that members
of the Society shall be guided by the foregoing rules.
30
Journal of Iowa State Medical Society
[January, 1923
and it is hereby expressly declared that Avhere the
member of the Society does not comply with the
foregoing rules he shall not be entitled to the benefits
of the defense fund, unless upon proper showing to
the medical defense committee satisfactory excuse
for not complying with the rules is established.
10. The Society will pay for the services of local
counsel, provided they are employed under the di-
rection of the regular attorneys for the Society and
not otherwise.
11. Members should carefully read these rules,
because they must be strictly observed to obtain the
benefits provided.
Dr. D. S. Fairchild, Sr., Clinton, Chairman,
Dr. Lewis Schooler, Des Moines,
Dr. H. B. Jennings, Council Bluffs,
C. M. Dutcher, Iowa City, Attorney for the Society,
^Members of the Committee.
SMALL-POX IN KANSAS CITY
The mild form in which small-pox has ap-
peared in the United States during the last few
years, has destroyed the healthy fear we have had
of the disease in past years, and has made us
neglectful of the certain means of safety within
our reach. During this recent period, we have
been afflicted by a certain class of people who
appear to be opposed to the application of scien-
tific methods of preventing disease. The small
number of deaths from small-pox in recent years,
has encouraged the anti-vaccination propaganda,
and to this may be added the natural indifference
of the American people to safety provisions. But
recent indications show that high mortality is not
altogether of the past. This is shown in the re-
cent outbreak of small-pox in Kansas City, where,
during the months of September, October and
November not less than 100 deaths from the dis-
ease have occurred. From September to Novem-
ber 16, forty-three deaths have been reported.
During this period 149 cases have been admitted
to the isolation ward of the Kansas City General
Hospital.
The first official report showed that fifty had
never been vaccinated, twenty from three days to
eleven years before onset of disea.se marked “no
take” which means not successful vaccinations.
Successful vaccination scars from six to sixty
years, twelve. Only one critical case was reported
with a successful scar, vaccination administered
thirty-two years ago.
Number with successful scar four days pre-
vious to onset of disease four. Number whose
vaccination and disease occurred at the same time
two.
Two-thirds of the cases are confluent small-
pox and the remainder hemorrhagic and discrete.
An interesting fact is stated in the Kansas City
Star for November 15. “In these schools where
the majority of the children are of foreign par-
entage, the response to the vaccination order is
almost 100 per cent. This is due it is said, to the
fact that alien born persons have been accustomed
to vaccination.”
The official report on November 15 gives the
number of deaths from small-pox as sixty-three
which will bring the number of deaths at the close
of November well above 100, a loss of life alto-
gether unnecessary ; a sad commentary on Ameri-
can foresight.
Report November 27 gives the whole number
attacked by the disease 263 ; deaths 93 ; death rate
about 33^ per cent.
IOWA STATE UNIVERSITY NEWS
Dr. Don M. Griswold
Dr. Lawson G. Lowrey, assistant director of the
State Psychopathic Hospital, gave an address before
the Kansas State Committee on Mental Hygiene at
Topeka, December 8.
Miss Helen Stewart, director of public health nurs-
ing, Miss Anna Drake, of the State Tuberculosis As-
sociation, and Dr. C. S. Grant, of the State Board of
Health, have been appointed a committee to investi-
gate the organization of a bureau of public health
nursing in the state department of health.
The Johnson County Health League recently held
a meeting in Iowa City to further the cooperation
of the various voluntary health agencies in the
county, to eliminate overlapping and duplication, and
to encourage the work in all fields of public health.
Miss Nelle Morris has been added to the staff in
the school of public health nursing, to have charge
of the training of public health nurses in rural
hygiene and county nurse work.
!Miss Jessie Chapman is organizing her work as
city public health nurse so that the nurses in the
school of public health nursing will have practical
experience in municipal health work during their
course of training.
Miss iMabel Green has recently been added to the
staff of school of public health nursing and will
have charge of the school nursing course and will
also carry on practical work in the parochial schools
of Iowa City.
Plans are already under way for a Christmas tree
at the children’s hospital. Friends from various
parts of the state who have the interests of these
crippled children at heart, are sending Christmas
cheer in various forms to these little patients. Miss
VoL. XII, No. 1]
Journal of Iowa State Medical Society
31
Averth, supervisor of nurses at the children’s hos-
pital, says that in the past they have received far
more candy than the children could digest and that
the thing's they enjoy the most are toys that “will
go.”
The Y. M. C. A. are showing their interest in the
little folks at the children’s hospital every Friday
evening by furnishing a reel of moving pictures, and
piano player or violinist. These pictures and this
music is especially selected for children and is very
much appreciated by the little patients. Each Sun-
day afternoon the Y. M. C. A. hold a concert at the
children’s hospital, using the piano which was fur-
nished the hospital by the Y. lil. C. A. of the Uni-
versity. Children’s songs and stories make up the
program which is very much enjoyed by the patients.
Dr. R. V. Funston, formerly assistant in the de-
partment of orthopedics, has been made instructor
in that department.
Dr. Randolph Reynolds of New Haven, Rhode
Island, a recent graduate of Columbia Medical
School, has been appointed interne in the department
of orthopedic surgery.
Dr. D. R. Tilson, a recent graduate of Bellevue
Medical College, has been appointed second assist-
ant in the department of orthopedics.
Earl Waterman of the extension division, and Dr.
Don M. Griswold, college of medicine, attended the
annual meeting of the American Public Health Asso-
ciation in New York, November 8 to 18. Dr. Gris-
wold was elected a member of the governing council
of the organization.
Dr. James Thompson, a former student in the
medical college, died recently at North Yakima,
Washington.
A committee of the faculty of the University of
Belgrade, Servia, that is in this country studying
the organization and operation of the leading medi-
cal schools, spent two days in Iowa City. The com-
mission is composed of Dr. Nicholitch of the minis-
try of public health. Dr. Stanovic, professor of in-
ternal medicine, and Dr. Johnivitch, professor of
pathology.
The public health education section of the exten-
sion division recently sponsored a tour of the “Health
Fairy” of various cities of the state. This rather
unique way of presenting health facts to children
met with hearty responses wherever the plays were
shown.
The first examination of the National Board of
Medical Examiners, under the new plan, in parts
I and II will be held as follows:
Part I, February 15, 16 and 17 (1922) inclusive.
Part II, February 20 and 21 (1922) inclusive.
Applications for examination should be received
no later than January 15, 1922. Application blanks
and circulars of information may be had by writing
to the secretary. Dr. J. S. Rodman, 1310 Medical Arts
building, Philadelphia, Pennsylvania.
SOCIETY PROCEEDINGS
Audubon County Medical Society
The Audubon County Medical Society met Friday
afternoon in the office of Dr. R. F. Childs, in a reg-
ular business session. The greater part of the meet-
ing was taken up with a discussion regarding the fee
bill, which was lowered and reconstructed. The
yearly election of officers was also held. Dr. Jacob-
sen of Exira was elected president. Dr. W. H. Hal-
loran, vice-president and Dr. R. F. Childs, secretary
and treasurer.
Austin Flint-Cedar Valley Medical Society
The meeting was called to order by the presiden*^.
Dr. Peters, at 10:00 A. M., November 8 at Fort
Dodge. The minutes of the last meeting were read
and approved. The morning program was given as
follows:
Surgical Injuries to the Bile Passages — Dr. A. E.
Acher, Fort Dodge.
The Diagnosis of Epidemic Encephalitis — Dr. C. G.
Field, Fort Dodge.
Pre-operative Management of Prostatitis — Dr. A.
A. Schultz, Fort Dodge.
These three papers were most excellent and were
freely discussed. Dr. A. G. Shellito requested to
give his paper following Dr. Schultz’ paper rather
than wait for the afternoon program in order that
he might make more convenient train connections
home to Independence. The society gladly granted
his request and his paper on Conservative Surgery
in the Female Pelvis was read and discussed. The
meeting then adjourned for the lunch hour.
At 1:30 P. M. the members reassembled and Dr.
W. L. Bierring of Dcs Aloines presented a medical
clinic. Some of the cases were as follows: Trans-
position of the heart; cerebral tumor; cerebellar
tumor; mitral stenosis with mitral regurgitation;
gall-bladder disease; and a very interesting case from
South Africa which was considered to be a form of
hydatid disease of the liver.
Great credit is due the members of the Fort Dodge
medical profession for the excellent way in which the
histories, laboratory findings, physical findings and
x-ray plates were presented at the clinic. The clinic
was a thorough success from every standpoint and a
keen interest was shown by those in attendance.
Dr. J. T. Strawn and Dr. Oliver J. Fay, both of
Des Moines, did not reach the meeting in time to
appear on the program and later word informed the
society that they were unable to get to Fort Dodge
by auto as they started to do.
32
Journal of Iowa State IMedical Society
[January, 1922
The business meeting was held following the med-
ical clinic. Dr. Small, chairman of the committee on
the revision of the constitution and by-laws, re-
ported. The following amendments to the by-laws
were offered:
1. Chapter 5, funds and expenses, amendments
to insert the words “two dollars” instead of “one
dollar,” so that the chapter shall read: “The ad-
mission fee to membership in this society shall be
two dollars.”
An amendment was also offered that the dues
be changed from one dollar to two dollars per year.
This amendment was seconded by Dr. Gardner. Dr.
Small recommended that the secretary read the con-
stitution and by-laws in order that those present
might have an opportunity^ to make suggestions for
amendments which could be referred to the commit-
tee on revision for action. It was moved by Dr.
Studebaker that this be done and the motion was
seconded by Dr. Gardner, following which the con-
stitution and by-laws were read by the secretary.
Further amendments offered were as follows:
Dr. Small amended chapter 5 to include the wmrds
“and annual dues” after the words “admission fee to
membership.” This was seconded by Dr. Kenefick.
Dr. Kern amended chapter 3, section 2, by adding
“to deliver annual address at the annual midsummer
meeting.” Seconded by Dr. Small. Dr. Small moved
that the midsummer meeting only last two days as
called for in the by-law's, chapter 2, section 1. This
was seconded by Dr. Gardner. Carried. The secre-
tary was instructed to have all offered amendments
printed in the next program, as well as the names of
the physicians who applied for membership at this
meeting. Dr. Kenefick discussed the question of the
board of censors, and, in view' of the fact that the
last three presidents were Dr. Kern, Dr. Landon
and Dr. Phillips, the point was made that these
three men should now compose the official board of
censors.
The following applications, which were presented
at the midsummer meeting in Clear Lake in 1921,
and which had been approved by the board of
censors, were read by the secretary for election to
membership: Dr. E. Henely, Xora Springs; Dr. H.
W. Barbour, Dr. A. H. Chilson, Dr. Geo. M. Crabb,
Dr. L. R. Woodward, Dr. C. B. Tice, Dr. B. Ray-
mond Weston, Dr. O. Franchere, Mason City; Dr.
Leslie Fenlon, Clinton; Dr. T. A. ^laher, Bancroft;
Dr. R. K. Reuber, Klemme; Dr. C. C. Wiggins,
Osage; Dr. A. E. Conrad, Decorah; Dr. N. O. Dal-
ager. Dr. Jane ^McIntosh Wright, Dr. E. L. Wurtzer,
Dr. F. A. Barber, Clear Lake.
It was moved by Dr. Small that a vote on all of
these applicants be taken by ballot and if any “noes”
were found in the official tabulation of the ballot,
then a vote would be taken separately on each ap-
plicant. This was seconded by Dr. Studebaker and
the ballot taken. All applicants were unanimously
elected to membership.
The following applications for membership w'ere
received at this meeting: Dr. E. W. Kersten, Dr.
A. A. Schultz, Dr. Geo. Gibson, Fort Dodge; Dr.
R. S. Fillemore, Corwith; Dr. L. G. Patty, Carroll;
Dr. A. W. Patterson, Dr. A. P. Maloney, Fonda; Dr.
R. F. Etienne, Dr. Forest F. Hall, Webster City;
Dr. Garner F. Parker, Pocahontas; Dr. E. B. John-
ston, Clear Lake; Dr. A. W. Beam, Rolfe, Dr. Chas.
L. Jones, Gilmore City; Dr. T. J. Kellejq Marathon.
The secretary was instructed to look up an amend-
ment which the members thought was passed about
three years ago making the president the chairman
of the program committee. Dr. Gardner invited the
society to hold its midsummer meeting, next July,
at New Hampton. It was moved by Dr. Kern and
seconded by Dr. Small that the invitation be ac-
cepted. Carried.
It was moved by Dr. Small that the meeting be ad-
journed to reconvene in case Dr. Strawn and Dr. Fay
of Des Moines arrived but to remain adjourned if
they did not come. Seconded by Dr. Studebaker,
carried. The meeting adjourned to remain adjourned
as the physicians did not arrive.
A most delightful banquet was served at 6:30,
which was well attended and those present expressed
much enthusiasm over the singing, toasts and read-
ings that were given. A jazz orchestra furnished
music during the banquet which made it rather diffi-
cult for some of the members to remain in their
chairs. L. A. West, Sec’y.
Chickasaw County Medical Society
At a meeting of the Chickasaw County ^ledical
.Society held November 23, the following officers
for the ensuing year were elected: President, L. P.
Reich, Fredericksburg; vice-president, !M. J. Mc-
Grane, New Hampton; secretary-treasurer, Paul E.
Gardner, New Hampton; delegates, N. Schilling and
L. P. Reich.
Clarke County Medical Society
The Clarke County Medical Society held their
regular November meeting at the city library Tues-
day evening, November 29. The meeting was called
at 1 :30 when the president of the society. Dr. H. I,.
Hollenbeck, introduced Dr. B. I-. Eiker of Leon. Dr.
Eiker addressed the meeting on The Doctor and the
Public School and manj' of the points in connection
with this most important subject were touched in
Dr. Eiker's address. ^Members of the school board
of the City of Osceola had been invited by the county
society to hear Dr. Eiker, and they were impressed
with the important part the medical profession plays
in modern school problems. Miss Rose Kirby,
county Red Cross school nurse, was also an invited
guest of the society.
Eollowing Dr. Eiker’s talk Dr. Samuel Bailey of
Mount -A^yr brought up and discussed the Problems
of the ^ledical Profession. Dr. C. E. Bamford of
Centerville, the head of Bamford Clinic, addressed
the physicians on Fractures of the Long Bones from
a Surgical Standpoint.
Doctors from Winterset, Murray, Indianola, Leon,
VoL. XII, No. I]
Journal of Iowa State IMedical Society
33
Grand River, Garden Grove, Leroy, Woodburn, Lori-
mor, Mount Ayr, Centerville and Humeston were
present at the meeting.
Clay County Medical Society
The Clay County Medical Society entertained the
members of the Upper Des Moines Medical Society
at a banquet at the Hotel Tangney Thursday, De-
cember 1. All doctors in Clay county and all mem-
bers of the Upper Des Moines Society, of which
there are fifty-three, were invited to attend and in
addition representatives of the various civic organiza-
tions in Spencer were extended special invitations.
At five o’clock a business meeting of the doctors
was held in the Commercial Club rooms and election
of officers took place. There was a presentation of
case reports and miscellaneous business was trans-
acted at this meeting. The banquet was at seven
o’clock in the hotel dining room, and a special pro-
gram followed the dinner.
President Wilson Cornwall, speaking on behalf of
the Spencer Commercial Club, made the address of
welcome, and there were talks by Dr. George Dono-
hue, superintendent of the State Hospital at Chero-
kee on The Advisability of Voluntary Commitment
to the State Hospital for the Insane; by Dr. J. J.
Strawn of Des Moines on The X-ray in Gastric Le-
sions; by Dr. E. W. Sproule of Peterson on Calcium
Metabolism; and by Dr. E. E. IMunger of Spencer on
Our Health.
Johnson County Medical Society «
At the December meeting of the Johnson County
Medical Society, the officers elected for 1922 were;
President, J. H. Wolfe; vice-president, George C.
Albright; secretary-treasurer, Law'son G. Lowwey;
delegates, H. J. Prentiss and W. F. Boiler; censor,
N. G. Alcock, all of Iowa City.
Ringgold County Medical Society
A meeting was held by the Ringgold County Medi-
cal Society recently. On the program were a number
of doctors from outside. Those present being Drs.
H. S. Forgrave and E. S. Ballard of St. Joseph,
Missouri, M. Bannister of Ottumwa, and G. N. Ryan
of Des Moines. There was a large attendance.
Scott County Medical Society
At a recent meeting of the Scott County Medical
Society, the following officers were elected for the
ensuing year: President, B. H. Schmidt; vice-presi-
dent, H. P. Barton; secretary, W. E. Foley; treas-
urer, S. G. Hands; delegates, A. P. Donohoe and
W. C. Goenne; censor, E. O. Ficke, all of Davenport.
Story County Medical Society
The regular meeting of Story County Medical So-
ciety held at the Sheldon-Munn in Ames Wednesday
evening November 30.
There were physicians from Nevada, Roland, Col-
lins, Story City and Maxwell in addition to a large
number of the Ames physicians, attending the meet
ing, which followed a dinner in the hotel dining
room.
There were some interesting talks upon current
professional topics by Story county men. Dr. Gra-
ham of Collins gave a paper on The Phantom
Tumor. Dr. Snyder of Roland on Rheumatism and
Adamson of Ames on Pneumonia.
Those physicians present at the meeting aside
from the seven Ames doctors were Smith, Conner
and Houston of Nevada, Graham of Collins, Snyder
of Roland, Joor of Maxwell and Haream and Har-
mon of Story City.
Van Buren County Medical Society
The annual meeting of the county society will be
held in rest room, Keosauqua, Thursday, December
8. If weather and roads are unfavorable, meeting
postpones to Monday, December 12. Time 1:30
P. M.
This is the meeting at which we elect our officers
and attend to such other business as shall come be-
fore our annual meeting.
For our program, we have Dr. W. B. LaForce of
Ottumwa, who for several years has been engaged in
medical and missionary work in China. His talk will
be Medical and Other Conditions in China. Dr.
LaForce is an entertaining speaker and his topic is
something new and we are assured that we will hear
something worth while. As his work has been mis-
sionary as well as medical, and deeming that part
of his message will be along religious lines, you are
requested to invite the ministers and any others who
are interested along this line. Eespecially bring
your wives.
We shall look for you. It is due Dr. LaForce that
we give him a large and appreciative audience.
C. R. Russell, Sec’y.
Wapello County Medical Society
The Wapello County Medical Society held its an-
nual meeting December 5 at the Ballingall Hotel,
following a dinner and smoker at which twenty-
eight members were present.
Dr. Frank W. Mills, was elected president. Dr. L.
A. Hammer, vice-president. Dr. H. W. Vinson, sec-
retary and treasurer. Dr. J. F. Herrick was chosen
as the delegate to the convention of the State Med-
ical Society, with Dr. W. C. Newell as alternate. Dr.
Alurdock Bannister was elected a member of the
board of censors.
After the business meeting, interesting talks were
made by Dr. O. A. Williams, and Dr. C. A. Henry of
Farson. The Ottumwa physician spoke reminis-
cently of the Wapello County Society in the earlier
years of its organization. Dr. Henry's, subject was
The General Practitioner.
The doctors and dentists of Shenandoah enjoyed a
6 o’clock dinner at the Delmonico Hotel, Friday eve-
ning, November 11. Those present were: Dr. J. F.
34
Journal of Iowa State Medical Society
[January, 1922
Aldrich, Dr. T. L. Putman, Dr. W. F. Stotler, Dr.
M. O. Brush, Dr. E. J. Gottsch, Dr. Benjamin
Barnes, Dr. J. D. Kerlin, Dr. L. W. Lewis, Dr. H. N.
Richardson, Dr. J. M. Van Buskirk, Dr. J. D. Bell-
amy and Dr. E. S. White. Dr. Putman, president of
the organization was in charge and a general discus-
sion was conducted after the dinner hour.
Southwestern Iowa Medical Society
The forty-sixth annual meeting of the Southwest-
ern Iowa Medical Society was held at Fort ^ladison,
October 20, 1921. Dr. Edward LaForce, president,
in the chair.
Following the address of the president, Dr. C. A.
Boice of Washington read a paper: The Small Hos-
pital; Is it W^orth While? Dr. T. H. Chittum of
Wapello read a paper: Laboratory Service for the
Country Doctor. Dr. D. C. Brockman of Ottumwa;
The Sins of Omission are Greater than the Sins of
Commission. Dr. C. H. ^lagee of Burlington; Some
Phases of Prostatectomy. Dr. Richard L. Sutton of
Kansas City presented a discussion on Carcinoma
of the Nose and Face, illustrated by lantern slides.
Officers elected: President, Dr. O. A. Geeseke of
^It. Pleasant; vice-president. Dr. J. Spillman, Ot-
tumwa; secretary-treasurer. Dr. J. B. Crow, Burling
ton. Place of meeting, 1922, Burlington. There
were about fifty members present.
Northwestern Iowa Medical Society
Regular fall meeting held at Sheldon, Iowa, Wed-
nesday, October 26, 1921, with a banquet at Hotel
Myers at 7 P. M. Meeting called to order at Com-
mercial Club rooms at 8 P. 1\I.
Order of business: Call to order by the presi-
dent. Reading of the minutes of the last meeting.
Unfinished business. Miscellaneous business, in-
cluding election of new officers. Papers and dis-
cussions. Cyclic Vomiting, report of a case. Dr.
R. G. Mellen. Syphilis, Dr. G. L. Roark. Treatment
of Gonorrhea, Dr. A. J. McLaughlin, Sioux City.
Blood Transfusion, Dr. W. W. Cram.
Clinical cases. Announcements. Adjournment.
Committee on local arrangements: Drs. Brackney,
Myers and Brock.
Officers: H. J. Brackney, president, Sheldon; J.
W. Myers, vice-president, Sheldon; Jay M. Crowley,
secretary-treasurer. Rock Rapids. Censors: E. W.
Boslough, George, 1921; J. F. McAllister, Hawarden,
1922; H. L. Avery, Primghar, 1923; D. G. Lass,
Ocheyedan, 1924.
ORTHOPEDIC SURGEONS MEET IN IOWA
CITY
On November 11, the University and Children’s
Hospitals at Iowa City, Iowa, were honored by a
visit of one of the largest groups of distinguished
men who have ever gathered there. At this meeting
of the central states. Orthopedic Club which em-
braces the orthopedic field from Buffalo west to the
coast, all were interested in seeing the work carried
on by Dr. Steindler and his staff.
There is possibly no institution in the country
where there is being done more orthopedic work on
the upper extremity, and about one-half of the pro-
gram was devoted to this subject. There was a large
series of demonstrations of post-operative cases.
The greater part of the program was conducted by
Dr. Steindler. There was also a very interesting talk
by Dr. H. Winnett Orr, Lincoln, Nebraska, and
demonstrations by Dr. R. V. Funston of the chil-
dren’s hospital. Miss Prosser gave a talk on muscle
education in upper extremity surgery.
Following the meeting there was a banquet at
which moving pictures of operations and cases were
shown. From Iowa City the visitors proceeded to
Kansas City where the remainder of the meeting
was held.
HOSPITAL NEWS
^Members of the staff of Mercy Hospital, Fort
Dodge, were the guests of the Sisters of iUercy at
dinner Monday evening, October 31 on the occasion
of the annual meeting. The present officers were all
re-elected for the coming year. Dr. C. J. Saunders,
president; Dr. Robert Evans, vice-president; Dr.
A. A. Schultz, secretary-treasurer; Dr. W. W.
Bowen, chairman of surgical staff. Dr. Edward
Evans of LaCrosse, was a guest of the Fort Dodge
doctors. Dr. Evans gave a very able talk on hospital
problems. Dr. A. H. McCreight acted as toastmaster
and the following talks were given by members of
the staff. Recent Progress of Our Hospital, by Dr.
Edward Beeh; Duties of Staff Towards Hospital,”
Dr. Saunders; Medical Co-operation, Dr. A. E.
Acher; Importance of Full Records, Dr. W. W.
Bowen; Duties of the Teaching Staff, Dr. E. Ker-
sten; Hospital Laboratory Advantages, Dr. S. D.
Jones; Co-operation of Nurses, Dr. S. B. Chase.
At the second annual banquet and meeting of the
officers and the Alercy Hospital staff, Dubuque,
Wednesday night at the institution. Dr. M. J. Moes,
was elected president of the organization; Dr. W. A.
Johnston, vice-president, and Dr. C. E. Lynn, sec-
retary-treasurer. The retiring officers are Dr. W. A.
Becker, president; Dr. AI. J. ^loes, vice-president;
Dr. R. R. Harris, secretar)q and Dr. J. AI. Walker,
treasurer.
Dr. J. C. Painter, medical director of the Sunny
Crest Sanitorium, was at the banquet and spoke
highly of that institution, which had been provided
by the people of Dubuque county. He urged the
local physicians to co-operate with him in his work
and make the local sanitorium rank first among such
institutions in the State of Iowa.
Aliss Amy Beers, superintendent of the Jefferson
County Hospital, was elected president of the Iowa
VoL. XII, No. 1 1
Journal of Iowa State Medical Society
35
State Nurses Association at the association’s annual
convention at Iowa City, November 3.
A quiet zone about Finley Hospital, Dubuque, is
to be established in the near future, and signs erected
by the Finley Hospital directors, warning autoists
to this effect, action taken by the city council Friday.
Permission was given the hospital to erect these
“quiet zone” signs.
Over $6,000 worth of radium, the property of Dr.
Joseph W. Rowntree, has disappeared from Presby-
terian Hospital, Waterloo. Dr. Rowntree had been
using the precious material in the treatment of a can-
cer case. The radium was first discovered missing
Tuesday evening, October 23, and since that time a
still hunt has been made, but without results.
Dr. Erskine, Cedar Rapids, is in the city and using
an electroscope in an attempt to find the missing
metal. Yesterday, the patient’s room, the ashes from
the building and the laundry were gone over thor-
oughly with this instrument; but without success.
The latest development in the search is a consider-
ation of the plan to erect a cofferdam at the mouth
of the Sixth street sewer, which serves the district
in which Presbyterian Hospital is located, and pump
out the water.
Firemen from the city stations yesterday raked the
mouth of the sewer, but no trace of the lost metal
was found.
As soon as the radium disappeared Dr. Rowntree
notified the insurance company in New York. Im-
mediately plans were set in motion along the line of
a search in the hope of recovery. The monetary
loss involved is nothing compared to the loss to
humanity in general, as the supply of radium is
limited to five ounces in the whole world.
Miss Bernice Carlson departed Alonday for Ains-
worth, Nebraska, where she has taken the position
of superintendent of the Ainsworth Hospital.
The hospital is a new building just completed. A
three story building with full basement. The hos-
pital has sixteen rooms for patients, has an x-ray
apparatus and is thoroughly equipped throughout,
with all modern hospital conveniences. Miss Carlson
will be in charge. She is well qualified for the posi-
tion, and her friends wish her the fullest success.
The North Iowa Clinic, staff to St. Luke’s Hos-
pital, held its first annual meeting with election of
officers as follows:
Dr. C. E. Chenoworth, president; Dr. A. B. Phillips
vice-president; Dr. C. M. Franchere, secretary-treas-
urer. The resignation of Dr. A. C. Echternacht was
tendered and accepted at this meeting.
The Park Hospital at Mason City has added three
new physicians to its staff. Dr. C. E. Dakin, Dr. V. A.
Farrell, and Dr. H. D. Holman.
MEDICAL NEWS NOTES
The Physicians-Surgeons Exchange of Siou.x City,
which has been in operation four months, was unan-
imously indorsed by the Woodbury County Medical
Society at its meeting at the West Hotel.
This exchange is at the service of the public, day
and night, without charge. Anyone unable to locate
their physician may call the exchange but must name
the particular physician desired and information will
be given provided the physician is a member of the
exchange.
Dr. J. C. Painter, recently of the State Tubercular
Hospital at Kearney, has been named medical di-
rector of .Sunny Crest, Dubuque county’s institution
for treatment of consumption. Doctor Painter has
assumed his new duties.
The new medical director is known as one of the
foremost authorities on tuberculosis in the country.
He is a graduate of Rush IHedical College and holds
a B.S. degree. In war time Doctor Painter was a
captain in the United States Medical Reserve Corps.
Sunny Crest now has seventeen patients. Its ca-
pacity is forty.
Three Serbian doctors accompanied by representa-
tives of the Rockefellow Foundation arrived in Des
Moines October 29, 1921 to inspect local health cen-
ter methods.
The party includes Dr. George J. Nicholich, as-
sistant minister of public health, Tugo-Slavia, Bel-
grade, Serbia; Dr. Radenko Stankovich, profesor of
internal medicine. University of Belgrade; Dr.
George Ioannovich, professor of pathological anat-
omy, University of Belgrade; Dr. H. J. John, a Bo-
hemian surgeon, who is official interpreter for the
party, and Mr. Stubbs of the Rockefellow Founda-
tion.
The Serbians are making a tour of the United
States to study organized charities. They were in
the city only one day, as guests of the Greater Des
Moines Committee at Des Moines Club Saturday
noon and of the Public Welfare Bureau at their
“pep” meeting at Chamber of Commerce Saturday
evening. They will inspect the Health Center, Sat-
urday afternoon.
The Serbian commission, representing one of the
most progressive of the little governments overseas,
visited the College of ^Medicine, Iowa University, its
laboratories, anatomy department, amphitheatres,
hospitals, etc.
The visitors represent great institutions, and are
studying the work of the able superintendent of the
hospital. Dr. A. J. Lomas; of Dean L. W. Dean, the
efficient chief of the college, and of the many other
heads of departments, etc.
They came here, at the suggestion of the Rocke-
feller Institute, which recommended only a few othei
“high lights” in medical college activities — Cleveland,
36
Journal of Iowa State Medical Society
[January, 1922
Ohio; St. Louis, ^Missouri, and Rochester, Minnesota,
being the only others or almost the onl}" other hos-
pitals thus honored.
Dr. Henrj' A. John of Cleveland, and Dr. Frank
Bernard Stubbs of the Rockefeller Foundation, New
York Citj^ are introducing the distinguished visitors,
and President Walter A. Jessup, Dr. John T. ^Ic-
Clintock, Dr. Henry J. Prentiss and other S. U. I.
leaders will assist in entertaining them.
These gifted savants are as follows: Dr. George J.
Nicholich, assistant minister of public health, Bel-
grade, Serbia (Jugo-Slavia).
Dr. George Joannovich, professor of pathological
anatomy, Belgrade.
Dr. Radenko Stankovich, professor of internal
medicine, University of Belgrade Medical School,
Belgrade.
Dr. Arthur Steindler of Iowa University’s Hos-
pital, conducted a free clinic at Winterset, Iowa,
under the auspices of the Red Cross and the Madison
County Medical Association. ^lany people, with hip
deformities, etc., consulted him. Dr. Steindler was
an assistant of Dr. Lorenz of Vienna.
Notice is hereby given that the Kossuth County
Phj'sicians’ Credit Association has been organized
as a corporation under the laws of the State of Iowa;
that said corporation is named and known as Kos-
suth County Physicians’ Credit Association; that its
principal place of business is at Algona, Kossuth
County, Iowa; that the general nature of the business
of said corporation shall be the promoting, acquiring,
possessing and disseminating of useful business in-
formation including the credit standing and financial
responsibility of prospective or actual clients or pa-
tients of any' of the members of this corporation; ad-
justing controversies and misunderstandings which
may arise between any members of the corporation,
and the collection of any' bills, debts or accounts
owing to any' member of this corporation.
The authorized capital stock of this corporation is
$300 divided into shares of $10 each to be fully paid
in cash and not less than $100 of said capital stock
shall be subscribed and paid for at the time of the
commencement of the business of said corporation,
the remainder of said stock to be subscribed and paid
for as the board of directors of said corporation may'
hereafter provide.
The corporation will begin business on the date of
the issuance of its certificate of incorporation by the
secretary of state and will terminate at the expira-
tion of twenty (20) y'ears unless sooner dissolved by
two-thirds vote of the stockholders.
The affairs of the corporation shall be conducted
by' a board consisting of five directors all of whom
shall be stockholders of said corporation.
The officers of said corporation shall consist of a
president, vice-president, secretary and treasurer,
said officers and directors shall be elected as pro-
vided by' the by-laws of said corporation.
The highest amount of indebtedness to which this
corporation may' at any time subject itself shall not
exceed two-thirds of its paid up and outstanding cap-
ital stock; that the private property' of the stock-
holders of said corporation is exempt from its cor-
porate debts.
Dated this 15th day' of November, 1921.
Signed, Kossuth County Physician’s Credit Ass’n.
C. H. CRETZMEYER, President.
M. J. KENEFICK, Secretary.
The local telephone company, with the coopera-
tion of the doctors of the city', has just made an in-
novation that is sure to prove popular. It is a plan
whereby one may locate his phy'sician quickly at
any hour of the day or night, and without standing
at the phone for an hour or so in the endeavor.
What is called a doctor’s exchange has been es-
tablished. A special department at the central office
is informed at all times as to the whereabout of
every' physician in the city', and simply' by calling
number 116 and naming the doctor wanted, one
will quickly be put in communication with him,
whether he is at home, at his office, hospital, church
or club. In case he is out of the city' or on a lengthy'
call that information will be given also, so that the
one who seeks him will know just when his services
will be available. — Cedar Rapids Tribune.
PERSONAL MENTION
Col. D. S. Fairchild of Clinton, who is known
among a large circle of friends in Cedar Rapids, and
more especially among former service men and vet-
erans of the Spanish-American War, has become
chief surgeon of the Panama district. Word has
reached Clinton, his former home, that he with his
wife and son, are now at the new post. Regarding
his appointment to this post the Clinton Herald say's;
Friends in Clinton, mindful of the genius for or-
ganization, and applied science for sanitation dis-
played by Col. Fairchild on the ^Mexican border and
later with the Rainbow Division in France, are not
surprised that his period of devotion to reconstruc-
tion problems should have brought this still greater
honor. He will have direction of all the military
hospitals in Panama and will have the authority to
so regulate the zone as to make it a marvel of sani-
tation in its relation to U. S. A. activities there.
Col. Fairchild had completed the reconstruction
work at Washington and it has been a vast organiza-
tion. The medical reserve corps plans call for medi-
cal officers sufficient for an army of one million men.
This corps is made up of men who were in actual
service during the late war or were enlisted for
actual service and their rank in the reserve corps is
that which they held in the army when war activities
ceased. Appointment to the reserve corps is estab-
lished by military rule and the precedent is not
broken except through special act of the administra-
tion. Appointees are not forced to accept such ap-
pointments but those men who did not accept the
VoL. XII, No. 1]
Journal of Iowa State Medical Society
37
appointment have lost their opportunity for the re-
serve corps is filled. — Cedar Rapids Times.
Captain J. M. Weiss, formerly a practicing physi-
cian at Knoxville, Iowa, has been ordered to the
Philippine Islands. Dr. Weiss enlisted in the medi-
cal corps of the army at the breaking out of the war;
was stationed at Camp Grant. After the armistice,
was mustered out, but later re-entered the service.
Dr. Hugh Jenkins of Preston has arranged to spend
the winter at Tucson, Arizona.
Dr. Granville Ryan of Des Moines has been elected
president of the City Club, a social organization for
business men.
Dr. R. S. McClinton, a graduate of the Detroit
College of Medicine and Surgery, has purchased the
practice of Dr. W. F. Hamstree of Sioux Rapids.
Dr. Paul Gardner of New Hampton was elected
president of the American Railway Surgical Asso-
ciation which held its annual meeting in Chicago,
October 18, 19, and 20. Dr. Gardner has been an
active member for many years and was clearly en-
titled to direct the affairs of this most important
railway surgical association for the coming year.
Dr. E. R. Shannon returned today from Philadel-
phia, Pennsylvania, where he attended the American
College of Surgeon’s annual meeting. Drs. F. T.
Hartman, E. F. Stevenson and T. F. Thornton were
also in attendance.
Dr. and Mrs. H. C. Eschbach departed recently for
New York City where the Doctor will do some pub-
lic health work after which Mrs. Eschbach will go
to Oneida, New York, to spend Thanksgiving with
her father.
Dr. and Mrs. Thomas B. Throckmorton have gone
to Chicago, where the former will attend a confer-
ence of Constituent State Medical Associations as
secretary of the Iowa State Medical Society. From
Chicago, Dr. and Mrs. Throckmorton will go to Mil-
waukee to attend a meeting of the Tri-State Medical
Society.
A fellowship in the American College of Surgeons,
the highest surgical honor, was bestowed upon Dr.
Charles Ryan, 812 Forest avenue, Des Moines, while
in attendance at the meetings of the Surgeons of
North America in Philadelphia.
MARRIAGES
Dr. D. Powell Johnson, formerly of Muscatine, and
Miss lone Elizabeth Kneese of Muscatine.
OBITUARY
Dr. David C. Dinsmore died at the home of his
daughter, Mrs. Clara Ackerman of Iowa City, No-
vember 9, 1921, at the age of ninety-one. Dr. Dins-
more was born in York county, Pennsylvania, De-
cember 30, 1830. Graduated from the Western Re-
serve University Medical Department 1855 and lo-
cated in Martinsburg, Iowa; at the breaking out of
the Civil War, enlisted at Burlington in Co. I, First
Iowa Cavalry. He was made first lieutenant and
later captain of his company.
On April 2, 1862, he married Miss Cyrilla J. Andrew
of Lafayette, Indiana. At the close of the war Dr.
and Mrs. Dinsmore located in Kirksville, Iowa, where
he lived fifty-si.x years and practiced until age com-
pelled him to retire.
BOOK REVIEWS
OPERATIVE SURGERY
By J. Shelton Horsley, M.D., F.A.C.S.,
Attending Surgeon, St. Elizabeth’s Hospital,
Richmond, Virginia. With 613 Original Il-
lustrations. Price $10. C. V. Mosby Com-
pany, St. Louis, Missouri, 1921.
When a well known physician or surgeon writes a
new book, we at once read the preface for the rea-
son of the undertaking, and we sometimes find that
the author feels that there is an urgent need for the
message he brings, that somewhere a very important
place is vacant. We are, however, pleased to find
that Dr. Horsley offers no apology, but presents the
book to stand on its merits. After the text, the first
consideration is the character of the paper used, as
it has an important relation to the illustrations. This
the publishers have carefully seen too, and the illus-
trations which are so important to a work on opera-
tive surgery are well brought out.
We have in the beginning a chapter on general
considerations, in which are suggestions as to the
principles of biologic sciences, anatomy, physiology
and pathology; that mechanical dexterity is not nec-
essarily surgery, and that dexterity in operation
work is not so much sought for as a knowledge of
principles. Following, is a series of chapters on
drainage, sutures and instruments, also complications
of operations, infection, shock and hemorrhage, in-
cluding measures to meet these complications. A
chapter is given to the highl}- technical operation of
suturing blood-vessels, including reversal of the cir-
culation. Two chapters follow on ligation of blood-
vessels, and on aneurisms. A chapter each on oper-
ations on nerves and bone. An important chapter
on plastic surgery. These are repair operations for
the purpose of correcting deformities and restoring
function, and are often a test of the surgeon’s judg-
ment and skill, are often avoided by would be sur-
geons, for the reason the results may be easily ap-
parent. These chapters carry numerous helpful il-
lustrations. From this point on to the end of the
book may be found a consideration of operations on
to the several regions of the body.
In amputations, certain important rules are offered
in relation to the point where the amputation of the
thigh and leg should be made. In amputations of the
thigh a “stump shorter than five inches below the
perineum can rarely be fitted with an artificial leg
without a pelvic band.’’ In amputations of the leg
a point should be selected at least four inches above
the ankle if a satisfactory artificial leg is to be fitted.
38
Journal of Iowa State ]\Iedical Society
[January, 1922
The author is positively opposed to a Chopart, but
is friendlj' to a Sj'me. Amputations below the knee
in elderly people with gangrene of the foot or leg are
not satisfactory, as secondary amputation is neces-
sary, a Stephen Smith amputation through the knee
will give the best results. An artificial limb can be
best fitted if the amputation is supra-condyloid by
the Gritti-Stokes plan. The chapter on operations
for hernia is admirable, in that it is clear, and pre-
sents the important points to be observed in this
operation which is so closelj'^ related to economic
conditions.
THE MASTER OF MAX
By Hall Caine
The central subject of The Master of ^lan, by Sir
Hall Caine, which will be published on August 29th,
the strong conflict between public duty or religious
principles and private interest, has had a great fas-
cination for some of the foremost novelists, as in the
cases of Z^Irs. Barhauld (Art and Nature), Scott (The
Heart of ^Midlothian), Lockhart (Adam Blair), Haw-
thorne (The Scarlet Letter), Lj-tton (Paul Clifford),
Karl Emil Franzos (The Chief Justice), Stevenson
(Weir of Hermiston), Tolstoy (Resurrection), and
others.
There have often been great differences in their
treatment of the subject or often important resem-
blances. In some cases the person in whose soul the
conflict takes place is a clergyman; in other cases he
is a judge; in one case an advocate, in another a
juryman and in yet another a sister who holds the
fate of the sinner in the palm of her hand. The
spiritual responsibility has sometimes been the im-
mediate consequence of a sin, while sometimes it has
been the indirect result of it. The foundation has
nearly always been laid on actual occurrences,
though the authors have generalh- departed from the
facts as they found them. In nearly every instance
the sequel has been the triumph of public duty or
religious principle over private interest, but it has
differed widely in incident, the victim of the struggle
frequently dying in the act of achieving the victory
of conscience and less frequently being saved
through love (usually the love of a noble-hearted
woman) and the hope of a great resurrection.
Hall Caine in The Master of Man will probably be
judged by the measure in which his imagination has
brought new values, new questions and new mean-
ings to a subject of universal and enduring interest —
a great human subject (sin and its consequences)
that has perhaps never been new and can certainly
never be old.
THE ALLEN TREATMENT OF DIABETES
W. M. Leonard, Publisher, Boston
This book with progressive diet lists in the treat-
ment of diabetes by Dr. L. W. Hill and Rena S.
Eckman, is very valuable to the use of every prac-
titioner.
EYE, EAR, NOSE, AND THROAT NURSING
By A. Edward Davis, A.M., AI.D., Pro-
fessor of Diseases of the Eye, and Beaman
Douglass, IM.D., Professor of Diseases of the
Nose and Throat, both from the New York
Post Graduate School. Second Edition, En-
tirely Revised. F. A. Davis Co., Publishers,
1920. Price $2.50.
This book of 346 pages is meant simply as a guide
for nurses in the care of the various diseases of
the eye, ear nose and throat. The chapters are very
brief, in reality are sketches. The book begins with
chapters on the anatomy and Physiology of the Eye.
Eye diseases are divided into contagious and non-
contagious types, a short chapter being devoted to
each group. The chapter on Remedies and Applica-
tion, is length}^ about a paragraph being given to
each individual drug. The chapter on operations
gives the nurse her exact duties in preparing for and
at the time of operations. The eye section is con-
cluded by a very short chapter on what to do in
emergencies.
Fifty-nine pages are devoted to the anatomy, phy-
siology and diseases of the ear and their care by the
nurse. Part three consists of 186 pages dealing with
the nose and throat and their various conditions from
the viewpoint of the nurse.
This excellent book answers its purpose admirably
and can be highly recommended to both undergrad-
uate and graduate nurses. Dr. E. P. Weih.
THE SURGICAL CLINICS OF NORTH
AMERICA
June, 1921, Volume 1, Number 3. (Boston
Number). Published Bi-Monthly, W. B.
Saunders Company. Price Per Year $16.
An important series of clinics appear in this num-
ber by well known Boston surgeons of a younger
generation, a number of which we will be able to
notice in this review; first a series of head injuries
by Dr. Edward H. Nichols, classified as concussion
of the brain; fracture of the bony vault; fracture of
the base of the skull; laceration of the brain; intra-
cranial hemorrhage. Dr. William P. Graves presents
a series of cases given before the Boston Surgical
Society of unusual interest, among them is Radium
in the Treatment of Non-malignant Menorrhagia, in
which it appears that a dosage of 50 milligrams for
twelve hours is sufficient to arrest the menstruation
without permanent damage to the ovaries.
Dr. Robert B. Osgood considers tuberculosis and
angioma of the knee joint. Dr. Wyman Whittemore
contributes a paper of some length on Lung Abscess
based on a series of forty-five cases. Dr. Torr W.
Harmer gives a paper on Tendon Surgery.
A group of surgeons at the Massachusetts General
Hospital give an important clinic on the problem of
Renal Calculus with Special Reference of Treatment,
and Dr. F. J. Cotton a Reconstruction Clinic.
(Continued on Adv. Page xvi)
Journal of Iowa State Medical Society
XV
A Bloodless Field
is promptly produced by the appli-
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Suprarenalin Solution, 1:1000
— the stable and non-irritating preparation of the Suprarenal active princi-
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Ischemia follows promptly the use of
1 : 10000 Suprarenalin Solution slightly
warmed (make 1 : 10000 solution by adding
1 part of Suprarenalin Solution to 9 parts
of sterile normal salt solution).
In obstetrical and surgical work Pituitary
Liquid (Armour), physiologically standard-
ized, gives good results — Yi c. c. ampoules
obstetrical — 1 c. c. ampoules surgical.
Either may be used in emergency.
Elixir of Enzymes is a potent and palatable
preparation of the ferments active in acid
environment — an aid to digestion, corrective
of minor alimentary disorders and a fine
vehicle for iodides, bromides, salicylates,
etc.
As headquarters for the organotherapeutic
agents, we offer a full line of Endocrine
Products in powder and tablets (no com-
binations or shotgun cure-alls).
Armour’s Sterile Catgut Ligatures are made from raw ma-
terial selected in our abattoirs, plain and chromic, regular and
emergency lengths, iodized, regular lengths, sizes 000 — 4.
Literature on Request
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WTien writing to advertisers please mention The Journal of Iowa State Medical Society
XVI
Journal of Iowa State IMedical Society
I Post-Graduate Courses for Practitioners |
I Offered by j
} Washington University School of Medicine j
I St. Louis. Missouri !
I Post-graduate instruction will be offered, beginning April |
I 24. 1922, in internal medicine, general surgery, obstetrics, I
I gj-necology, pediatrics, orthopedic surgery, genito-urinary j
I surgery, neurology, dermatology, ophthalmology, lap'n- {
I gology and rhinology, otology, and current medical liter- I
I ature. Courses run from four weeks to one year; fees i
( range from S25 to $500. For full information, address i
The Dean, Washington University School of Medicine
St. Louis, Missouri
BOOK REVIEWS
(Continued from Page 38)
The August number of the Surgical Clinics of
North America is a Chicago number, and is an ex-
ceedingly valuable number. The contributors are
among the best known surgeons of Chicago. The
first contribution is by Dr. Arthur Dean Bevan, on
a subject that should enlist the attention of every
surgeon who uses the x-ray. The title is X-ray
Burns. Dr. Bevan gives a successful treatment which
should receive the thoughtful attention of all who
have to deal with this troublesome accident. Dr.
Joseph B. DeLee presents the subject of Acute Ap-
pendicitis in Pregnancy at Term. Many physicians
have been in doubt as to the best course to be pur-
sued in these cases. Dr. De Lee’s experience will no
doubt be helpful. An interesting case presented by
Dr. Frederick Christopher, under the title of Pyleph-
lebitis of Appendical Origin Simultating Lung Ab-
scess. This case is rather exhaustively considered on
account of the difficulty in diagnosis. Drs. Carl
Beck and Verne Cabot present a series of cases of
rare interest and importance to the general surgeon.
Dr. David C. Straus demonstrates three cases of
Amputation of the Thigh for conditions of unusual
interest and importance and should be extensivelj^
read.
A presentation of marked interest is by Dr. Daniel
Eisendrath at Cook County Hospital in relation to
the Ij'mphatics of the female breast in relation to
carcinoma. Other contributions are by Drs. A. J.
Oschner and John Nuzum. Dr. Allen B. Kanavel,
Dr. Wyllis Andrews, Dr. Carl B. Davis, and others
of equal value.
The Chicago number is one of the best issued.
Ever}' paper is of great value.
THE MEDICAL CLINICS OF NORTH
AMERICA
Boston Number, ^lay, 1921. Index Num-
ber. W. B. Saunders Company, Price, Six
Numbers $12 Per Year.
There are several valuable papers in this number.
The Right and Wrong Use of Diuretics by Dr. Henry
A. Christian. The paper is a short one but presents
important facts to be considered by the physician in
prescribing diuretics.
Dr. Francis Peabody at the Peter Brent Brigham
Hospital presents a valuable clinic on the Vital Ca-
pacity of the Lungs and Heart. Some important
problems are presented here that should engage the
attention of the practitioner.
Dr. I. Chandler Walker discusses the cause and
treatment of seasonal hay fever. After considering
the various causes he takes up the treatment; first
the skin test, to determine the specific pollen to
which the patient is sensitive, and with which he
should be treated. Having determined which pollen
gives a positive reaction, treatment is instituted.
From the experience of four seasons. Dr. Walker
found that fourteen injections of pollen solutions,
one week apart, gradually increasing the amount,
gave satisfactory results in the majority of cases. A
full account of the method employed is given. Rapid
Heart Action is considered by Dr. Samuel A. Levine,
in a clinic at the Peter Brent Brigham Hospital.
Dr. Elliott P. Joslin, gives some practical lessons
for the physician and patient in the treatment of
diabetes.
Dr. George R. Minot presents two curable cases
of anemia; Chronic Hemolitic Anemia; Pernicious
Anemia of Pregnancy; Myxedema with Anemia.
Vaccine Treatment of Asthma is presented at some
length. Other important clinical discussions are
presented which we have not the space to consider.
The Boston number is of unusual interest and im-
portance.
NOSTRUMS AND QUACKERY
Articles on the Nostrum Evil, Quackery
and Allied Matters Affecting the Public
Health Reprinted with or Without ilodifica-
tions, from The Journal of the American
Medical Association. Volume II, Illustrated,
832 Pages. Published by the American Med-
ical Association, 535 N. Dearborn Street,
Chicago, Illinois. Price, $2.
Ten years ago the American ^ledical Association
published the first edition of the first volume of
this book. A year later a second, and enlarged edi-
tion of the first volume was issued. Since that time
The Journal of the American IMedical Association
has published, week by week, articles on the nostrum
evil, quackery and allied matters affecting the public
health. All this material has been collected and ap-
pears in the present volume.
Quackery can never be defended; the “patent med-
icine” business, however, need not be fundamentally
fraudulent. There is a place for home remedies for
the self-treatment of simple ailments. Unfortunately,
the home remedies of today are, generally speaking,
those secret nostrums commonly called “patent med-
icines” and the methods of “patent medicine” promo-
tion make these products a menace to the public
(Continued on Adv. Page xxviii)
Journal of Iowa State Medical Society xxvii
LABORATORY AND X-RAY
I DR. THOS. A. BURCHAM
I Practice Limited to
X-RAY DIAGNOSIS
1 Radium and X-Ray Treatment
I 1104 Bankers Trust Bldg.
1 Des Moines, ----- Iowa
ANNA P. A. GLOMSET, B.S.
DIR. OF PATHOLOGIC LABORATORY
Specialty — Blood Chemistry — Instruction in
Laboratory Technic
519 Iowa Bldg., - - Des Moines, Iowa
DR. CLYDE DEE BOTHWELL
Practice Limited to
X-RAY DIAGNOSIS
RADIUM AND X-RAY TREATMENT
Oelwein, ----- Iowa
DR. JULIUS S. WEINGART
Practice Limited to
PATHOLOGY
Private Laboratory
1013 Fleming Building Des Moines, Iowa
DR. C. N. O. LEIR
X-RAY AND ELECTRO-THERAPEUTICS
TREATMENT OF MALIGNANCIES
216 Utica Building
Des Moines, ----- Iowa
7
j
DOCTOR
This space is for you
NERVOUS AND MENTAL DISEASES
❖ —
I DR. TOM BENTLEY THROCKMORTON
Special Attention to
NEUROLOGY
922 Bankers Trust Bldg.
Des Moines, Iowa
—
DR. LAWSON G. LOWREY
Practice Limited to
CONSULTATIONS IN PSYCHIATRY
The Psychopathic Hospital
Iowa City, Iowa
— — ^
DR. GERSHOM H. HILL
ALIENIST
Phones:
Retreat, Drake 85 — Residence, Drake 4871
Des Moines, ----- Iowa
DOCTOR
i
This space is for you |
I
(
I
WANTED — A competent physician and surgeon to locate in a good Iowa county seat town of about
5000 population; excellent schools; office well located, established ten years; fixtures, instruments and
drugs. Address X, care this Journal.
1922 DUES
iiiiiiiimiiiiiiiiiiiiiiimiiiimtiniimiiiiiiiiiiiiimtiiimmiiimiiiiiimiiiiiiimMnmitiiimiiiiiimiiiiiiiiiiiiiiiiiiiiiiiiimiiimiKiMii
The Dues to the County and State Medical Society
are due January 1, 1922. Please make payment to
the Secretary of your County Medical Society now.
Tom B. Throckmorton, Secretary
xxviii
Journal of Iowa State Medical Society
BOOK REVIEWS
(Continued from Adv. Page xvi)
health. The average “patent medicine” is so adver-
tised as to frighten well people into the belief that
they are sick for no other purpose than that of caus-
ing them to purchase the nostrums.
The present volume is a veritable encyclopedia of
information on the subject it treats. The book con-
tains nineteen chapters. The titles of some of these
are: Alcohol, Tobacco and Drug Habit Cures; Con-
sumption Cures; Cosmetic Nostrums; Deafness
Cures; Epilepsy Cures; Female Weakness Cures;
Nostrums for Kidney Disease and Diabetes; Medical
Institutes; Miscellaneous Nostrums; Obesity Cures;
Quackery of the Drugless Type and Tonics, Bitters,
Etc.
This partial list of chapters gives but a poor idea
of the vast fund of information contained in the
book. To make the volume still more valuable it
contains an index of twenty-two pages, two columns
to the page, which includes references to every article
appearing in the first volume of Nostrums and
Quackery as well as to all articles in the present
volume.
The book is free from stilted or highly technical
language. The articles have evidently been written
with the idea that the facts they contain belong to
the public. In the Preface, it is emphasized that the
work which this volume represents is wholly educa-
tional in character — not punitive. The matter that
appears in this book has been prepared and written
in no spirit of malice and with no object except that
of laying before the public certain facts the knowl-
edge of which is essential to a proper conception of
community health.
ESSAYS OF SE'RGICAL SUBJECTS
By Sir Berkely Moynihan, K.C., M.G.,
C.B., Leeds, England. Illustrated. W. B.
Saunders Company, 1921, Price $5 Net.
This book contains a number of essays that have
appeared in medical journals during the past few
years of notable interest. This gifted surgeon has
the faculty of saying things the medical profession
would most like to hear. The first of this collection
is the Murphy Jilemorial Oration, delivered at the
Montreal meeting of the American College of Sur-
geons; it is most eloquent tribute to the memory of
one of America’s greatest surgeons. There are al-
together nine essays, six on specific surgical subjects
and three on general subjects, one as above noted — a
tribute to Dr. Murphy — one entitled the Gifts of Sur-
gery to ^Medicine, and one The ^lost Gentle Profes-
sion Delivered at the Annual Prize Distribution of
the Nursing Staff of Leeds Plospital. Those who
have had the privilege of listening to Sir Berkely
will appreciate the value of his contributions and the
pleasure to be derived from reading his essays.
THE SURGICAL CLINICS OF NORTH
AMERICA
Issued Serialy, One Number Every Other
IMonth. Wk B. Saunders. Price, Paper $16.00
Net; Cloth $16.00 Net.
Some time ago, we called attention to the new
series of these serial publications in surgery; we have
before us the second number by New York con-
tributors.
The first is a series of cases by Dr. John F. Erd-
man of the Post-Graduate Hospital. Dr. Willy
Meyer of Lenox Hill Hospital considers a subject
well worth the attention of the young surgeon who
desires the favorable opinion of his patients, which is
nothing more or less than the importance of posture
in post-operative treatment. There are certain acci-
dents that follow surgical operations which Dr.
Meyer believes could be lessened by posture; besides,
there are postures that contribute to greater comfort
which patients are grateful for. Dr. Eugene H. Pool
at the New York Hospital presents that interesting
condition known as cervical rib. Dr. John A. Hart-
w^ell presents a series of interesting cases. Dr. Fred
Albee takes up plastic surgery of the hip and femur
to which he has contributed so much. Dr. Leo
Buerger presents some important lectures on com-
plications of urinary lithiasis.
Dr. Byron Stookey from the Neurological Insti-
tute presents some very important observations on
brachial plexus injuries.
NEW AND NON-OFFICIAL REMEDIES
During November the following articles have been
accepted by the Council on Pharmacy and Chemistrj'
for inclusion in New' and Non-official Remedies:
G. W. Carnrick Co.:
Amylzjune Capsules.
^lerck and Co.:
Bromipin 10 per cent,
lodipin 10 per cent. Tablets.
Powers-Weightman-Rosengarten Co. :
Theobromine — P. W. R.
Schering and Glatz:
Xeroform S. and G.
E. R. Squibb and Sons:
Diphtheria Immunity Test (Schick Test) —
Squibb.
Diphtheria Toxin — Antitoxin ^Mixture — Squibb.
WANTED
copy of the Iowa Medical Journal Yolume iv.
Number 1, 1898, also Yolume vi, Number 9, 1900.
The receipt of these issues would be appreciated by
this Journal, 901 Bankers Trust Bldg., Des iMoines, la.
tEfje Jfoumal of tfjc
3$otua ^tate jDleliical ^cietp
VoL. XII Des Moines, Iowa, February 15, 1922 No. 2
THE RELATION BETWEEN THE SPEC-
IALIST AND THE PROFESSION*
Robert M. Lapsley, M.D., Keokuk
Address of Chairman
Owing to the numerous problems coming up in
practice, I decided to consider the relation be-
tween the various specialists to each other, and
the remainder of the profession.
.So far as medical education has developed, it
is still possible for anyone who has a license to
practice, to call himself a specialist on any subject
he desires, regardless of his particular training.
In course of time, no doubt, it will become nec-
essary for a specialist to have training along the
line he expects to practice, and will not be so
easily possible for a person in general practice in
one town to take a six weeks’ cour.se, and locate in
another as some variety of specialist.
It is even now much wiser for a specialist to
start with a good groundwork, as competition is
growing more close in the medical and hospital
centers, although many rural communities have a
shortage of doctors.
It seems wiser now for a young man to enter a
specialty after a good hospital training, than later
in life, as it is not only more easy to assimilate
ideas, but the development of technical skill is
much more easy, and it is probably almost impos-
sible to develop it in later life.
Even such a specialty as most of us practice is
so comprehensive, that most of us are not compe-
tent in all branches, and it seems advisable to send
some of our cases to the other specialists, better
equipped for the work, unless they can be grouped
together.
Group practice is gaining in popularity, as car-
ried out in some of its forms, either an office
group, a hospital group, or a college group, and
we all can develop some of the advantages through
the hospitals.
No doubt a closely bound group would be the
nearest an ideal, if all of the members were
*Presented before the Seventieth Annual Session, Iowa State
Medical Society, Des Moines, Iowa, May 11, 12, 13, 1921.
Section Ophthalmology, Otology and Rhino-Laryngology.
anxious to do their best for the relief of suffering
humanity, were industrious, and unselfish, and
competent of doing scientific work, but such an
ideal can not always be reached, and, so much of
the benefit of group practice will have to be
gained from people not working as a unit.
We should try to cooperate together as fully as
we can toward diagnosis and treatment, and it oc-
curs to me that an ophthalmologist is the best
person, if properly trained to treat disorders of
the eye, and that usually such cases will go to him
either directly, or be referred by some other phy-
sician, but there are many cases of eye trouble
that the patient’s own physician can treat, and I
see no reason why we should be jealous or com-
plain of his treating them, so long as the treatment
is a proper treatment.
We should not, because our work is limited to
that kind of work expect every case, but should
expect only the cases that want to come to us,
or that would be sent by some one who recognizes
us as superior in ability.
On the other hand I see no reason why the gen-
eral practitioner should complain if the patient
selects an eye specialist in the first place without
consulting him, nor do I see any reason why when
the case is sent by one physician to another who
is a specialist, that it should not be left to his
judgment about the future treatment, unless it is
sent only for diagnosis or consultation.
One of the difficult tasks of the specialist is to
have a case partly referred to him, enough to
throw some responsibility on him, but not giving
him a chance to follow the treatment.
The idea I have hoped to bring out is that one
physician should not handicap another when seek-
ing his aid, by too many strings to the patient.
The same trouble comes up here that I mentioned
in group practice as a possible trouble.
Each physician has to be generous in his feeling
and action to the other, and if one is not inclined
to be so, it makes it hard for the other.
One very important point I wish to mention, is
care in regard to criticism of what some one else
has done. It may even appear to be just to criti-
40
Journal of Iowa State Medical Society
[February, 1922
cise, but, no doubt, if you have practiced long, you
have had cases of your own come back, that if
some one else had operated on, or treated, you
would think there was not proper skill used,
judging only from the appearance, and what the
patient says, and you may know when the diffi-
culties you had to encounter were considered, it
was really skillful work.
This may sound like an address to a group of
medical students, but it is not given without hav-
ing observed the many petty annoyances about
getting along in the profession after graduation.
The one great aim is to relieve suffering in the
best way possible, and we should always consider
the patient’s interest first, but to do the most good,
we should tiy' to utilize other people’s knowledge,
with ours, and try to maintain the respect of the
public for our profession, by not belittling each
other.
THE :\1EDICAL PROFESSION*
Erank Billings, IM.D., Chicago
The general practitioner who is essentially the
family physician is the most important factor In
the community in welfare work. By education
and experience he is especially qualified to under-
stand fully the causes of, and the prevention of
disease. If he gives the matter attention his edu-
cation and experience enables him to comprehend
readily the detrimental influence of unhygienic
and poor social conditions in relation to the health
of the community. In any plan or program which
may be made, the domiciliary visitation of the
general practitioner must be considered as a nec-
essary fundamental pre-requisite in the conserva-
tion of the health of the community. The in-
timate relationship which exists between the fam-
ily physician and his patients and the influence
which he is able to exert upon the members of the
community in consequence, is of the greatest im-
portance in health work.
It seems necessary to pause at this point and to
discuss the general medical practitioner more
fully. It is recognized today that the general
medical practitioner of former years does not oc-
cupy the same relative position in the medical
profession. The evolution of modern medicine,
the advance in the standards of medical education
has stimulated the ambitious medical student and
recent graduate, to enter special fields of prac-
tice. In consequence, comparatively fewer grad-
uates take up the general practice of medicine.
*From the paper read by Dr. Frank Billings, at Creston, Session
of Iowa State Conference of Social Work, September 27,
1921.
The allurements of the city deprive the rural dis-
tricts of the proper share of medical practition-
ers. In the rural districts of some states, there is
not only a scarcity of medical practitioners but
they number among them but few of the recent
graduates. And yet, some of the members of the
medical profession, who are engaged in teaching,
whose judgment we must accept, the statement is
made that the number of physicians graduated by
the medical schools of the countr)-, is sufficient
to supply the needs of the public were these prac-
titioners equably distributed where their services
are most needed.
Our Present System of Medical Education
In the opinion of the writer the chief fault for
the lack of a sufficient number of general practi-
tioners in rural districts, especially and also in the
city, lies at the door of the medical schools. In
the evolution of modem medicine, there has been
an irrational coincident development of the cur-
riculum of the medical school. The present cur-
riculum tends to specialism of the undergraduate
student. He does not receive the broad training
necesary for the general practitioner. Each mem-
ber of the faculty is usually a specialist, and is
most likely to teach the student the facts which
relate to his own narrow field rather than to in-
struct him in the broad underlying principles of
medicine, and the relationship which the narrow
specialty bears to the parent subject — medicine.
Eor a moment let us consider the functions of
the family physician, and his responsibility to the
community he seiwes. He is responsible for the
safe and sane treatment of the family in illness
and injury and it is his duty to preserve individual
and community health. He counsels and advises
the family in regard to all problems which con-
cern it in relation to individual and general hy-
giene, public sanitation, education, community ob-
ligations and responsibilities, and the care of the
family in sickness and injury. Therefore, he
must have a good general knowledge of the prin-
ciples which underly epidemiology, immunology,
sanitation, medical jurisprudence, sociology and
education that he may act rationally when con-
fronted with the problems which relate to the ap-
plication of tried and proved measures of disease
prevention in the protection and welfare of the
multiplied families, the community for whom he
is responsible. He must advise, guide and safe-
guard the expectant mother through gestation.
He must so manage the labor that it will terminate
within a reasonable time, if that is possible, with-
out instrumental interference and without serious
injury to the mother and child. He must be able
VoL. XII, No. 2]
Journal of Iowa State Medical Society
41
to meet obstetric emergencies and especially to
recognize serious complications at an early stage
of labor so that consultation may be secured if he
alone is not technically able fully to safeguard the
two lives for whom he has assumed responsibility.
He must be able to give the best advise and man-
agement in the care of infants and children. This
implies the practical knowledge of modern infant
feeding and child welfare work. He must under-
stand the principles of psychology which enable
him to recognize psychopathologic conditions of
childhood and adult life. For these abnormal
mental conditions and their management and
treatment he will usually not assume responsibil-
ity, but will be able to direct the related responsi-
ble parents, or guardians, to physicians qualified
in this work. He must be well trained in diag-
nostic methods and be able generally to recognize
existing morbid conditions by physical examina-
tion, and by the application of simple functional
tests. His intimate acquaintance with members
of the family will enable him to trace the begin-
ning of pathologic changes more readily than a
strange physician and to promptly apply the
proper management and treatment while the con-
dition is remediable. He will command a selected
few tested and tried pharmacological products
which he will be able to use with skill and bene-
fit. His knowledge of the principles of immun-
ology and bacteriology will enable him to use rec-
ognized specific serums and bacterial vaccines,
with judgment and skill, both prophylactically and
therapeutically. In the general management of
his patients he will utilize rest, the proper en-
vironment and when needed available physical
treatment. Always he will be able to command
some form of hydrotherapy. Thermotherapy and
occupational therapy are always available. He
will have the proper conception of the value of
calisthenics and other active exercises in the
restoration of the functions of the heart, skeletal
muscles and joints. He will understand the prin-
ciples of asepsis and will be able to perform minor
and emergency surgery and especially to manage
fractures of the bones and uncomplicated joint
dislocations with confidence and success. He
will know his own limitations and will safeguard
the lives and health of his patients by reference
of major surgical conditions with which he is
unable to cope, to qualified surgeons.
Needs of the Service as the Basis of Educational
Standards
With this brief statement of the functions of
the general practitioner it is unnecessary to
enumerate the various steps which should be
taken in the training of the family practitioner.
With the curriculum compiled and formulated to
afford this training, the product of the medical
school would be able to give adequate and effi-
cient general medical service to the community
he desires to serve. This fundamental and gen-
eral training would best serve too as the basis of
the postgraduate training of those graduates who
may finally decide to enter general surgery, or
the narrower fields of practice in medicine and
surgery. The general practitioner of medicine
who is properly qualified, occupies a field of
endeavor which affords an opportunity of service
to mankind second to no other in the world. The
life of a general practitioner of medicine is one
filled with hardships, fatigue both bodily and
mental, exposure to the elements, loss of sleep,
is attended with great responsibility and is often
illy repaid by financial reward. On the other
hand, the life of the general practitioner is one
filled to overflowing with the joy of service ren-
dered to the poor and rich alike, with the satis-
faction which comes from intimate friendships
and the gratitude of the majority of the people
he serves, and with the contentment of mind
which is the reward of one who performs his
daily task honestly, energetically, disregardful of
the financial compensation he may receive, well
satisfied if his efforts have relieved suffering
and prolonged life.
Multiplication of Effectiveness Through
Coordination
What the individual general practitioner may
do in the program of community health is multi-
plied by organized medicine in its local, district
and state societies. Indeed it is more than multi-
plied by the actual number of the members of the
medical profession in the community, for by
cooperation among themselves and with lay and
semi-medical welfare organizations the combined
influence is many times greater than that of the
the individuals composing the group.
Community Health and Education
Health expresses a state of being hale, sound
or whole in body, mind or soul. So defined it is
rarely absolute, but is usually relative. In com-
mon usage one usually thinks of health as being
a condition free from physical disease or pain.
From the mother’s womb to the grave man is
in constant combat with physical, chemical and
other forces which modify his well being. Indi-
vidual and community health demands not only
comparative freedom from disease, but also an
environment which is clean, conditions of life
42
Journal of Iowa State Medical Society
[February, 1922
which are comfortable, wholesome food, satis-
factory provision for work and recreation, edu-
cational advantages in good schools and other
modern social conditions.
Education is directly related to health promo-
tion. That education system fails which does not
add to the academic instruction the teaching of
personal and general hygiene and physical educa-
tion. Simple amusements of an instructive kind
are essential to community health.
Agencies Which Promote Community Health
Let us now consider the agencies which will
diminish, modify or entirely prevent the action of
these causes of ill health.
Public Health Activities
In this country we have the United States Pub-
lice Health Service representing the activities of
the federal government in the matter of public
health. Each state has its department of public
health with organization varying in character and
with varying good and poor results measured bv
the condition of the health of the public. The
United States Public Health Service has done ef-
ficient work in protecting the people of the coun-
try against the importation of infectious diseases
and undesirable immigrants, through personal
examination of immigrants at points of embarka-
tion and at disembarkation, by quarantine, by the
regulation of interstate traffic, by the attempt at
prevention of pollution of interstate waters and
by investigation of the causes of, and the trans-
mission of infectious and of parasitic diseases of
man and animal. In some of our states the de-
partment of public health is thoroughly organized
including counties and smaller cities. In the
larger cities the municipal health departments
are usually well organized and do efficient work,
often at a very low per capita cost. Public
health work by the state, the county and by
municipalities is essential to the health of the
public served by each.
The Function of Public Health Service
The true province of the public health service
is the prevention of disease. The efficiency of
public health work is to be measured by the re-
sults of its work in the protection of the drinking
water at its source, in the establishment and en-
forcement of regulations for the prevention of
the spread of communicable disease, in the stand-
ardization and enforcement of regulations which
will prevent the contamination of milk and other
foods; in the establishment and enforcement of
regulations which will insure comfortable and
sanitary homes ; workshops and places of recrea-
tion and amusement. In the establishment and
enforcement of regulations to insure freedom
from infection and injury in railroad and ve-
hicular transportation; in the establishment and
enforcement of regulations which will insure the
inspection, the treatment for local infection and
the physical education of school children.
Through its personnel at headquarters and in the
field, it should standardize all health work.
Necessity for Cooperation of Local Medical Profes-
sion With Other Local Agencies
It should cooperate with the medical profes-
sion, the state and local medical and lay organi-
zations in all health and welfare activities. “Suc-
cess in public health work can he attained only by
cooperation with the members of the community
and must coordinate all of the activities which are
utdized in health and welfare work.” (Poregoing
italics our own.) Centralized operation of health
activities is apt to become bureaucratic and in any
event, is never as efficient as when it is decentral-
ized and operated by the people benefited.
Community Interest
Community interest must be aroused by the ed-
ucation of the people. This may be done by local,
district or statewide conferences, and by publicity
reinforced by lectures from the pulpit, the school
rostrum, at chautauquas and the like. The grade
and rural schools afford an opportunity for the
instruction of children by simply phrased lec-
tures and motion pictures, in many instances by
practical examples in the causes and prevention
of disease and in the maintenance of physical
health, by proper physical drill and play.
Importance of Local Boards of Education and
Teachers— as Active Agents
In addition to the pedagogic qualification, the
school teacher should be able to instruct the pu-
pils in the principles which embody well known
laws of health. Local, district and state so-
cieties, and associations which are organized for
the promotion of the public welfare, should co-
operate with the school authorities in carrying on
this health work in behalf of the children who are
destined to be the future citizens of the commun-
ity and who will be the better qualified in their
turn in the promotion of the health of their chil-
dren and of the other citizens of the community.
Local, district and state social associations or-
ganized for welfare work, must justify their exist-
ence by the result of their work. To be efficient,
all these agencies should cooperate and so co-
ordinate their work that there will be little or no
duplication of effort for the sake of economy of
VoL. XII, No. 2]
Journal of Iowa State Medical Society
43
money and time, and to insure efficiency and
productive results.
Local Churches as Factors in Reducing Local Death
Rates
The churches must take their part in the pro-
gram of health conservation. Christ preached
and gave an example of cleanliness of mind, body
and soul and healed the sick. The modern min-
ister may not heal the sick by the laying on of
hands, but he may from the pulpit and in the
spiritual care of his flock promote bodily cleanli-
ness, and an adherence to the simple laws of
health, which will aid in the prevention of dis-
ease and in the restoration of the sick.
Relationship of the Medical Profession to Lay and
Other Public Welfare Organizations
In the past, it has been the generally adopted
policy of individual medical practitioners and of
organized medicine to stand aloof from lay and
other public welfare organizations. This policy
has implied an element of jealousy on the part of
the medical profession toward lay organizations
engaged in welfare work and even against public
health officials. It is difficult to comprehend
this attitude on the part of the medical profession.
It is not based upon a selfish attitude and hos-
tility to the application of the measures of dis-
ease and injury prevention. The attitude of the
members of the medical profession and every day
practice has been one of cooperation in the appli-
cation of measures of disease and injury preven-
tion and no worthy member of the profession ever
refuses service to the sick, poor and the needy.
In general, one may say that in their point of
view and in their work, medical practitioners are
individualistic. There is more or less of a pride-
ful attitude in the assumption that the qualified
medical man alone should be left to deal with the
problems relating to the welfare of the com-
munity. But progress in relation to all the ac-
tivities of man, the lessons learned of the value of
group and mass effort as practiced in the World
War, and the evident need of greater activity in
welfare work in city and especially in rural dis-
tricts, has changed, or is gradually changing this
individualistic point of view of the doctor.
Iowa, the Leader
Iowa has taken the leadership in the adoption
of principles and policies which include in the
program, the interest and support of all the mem-
bers of a community in its welfare work. The
first movement in this direction was made years
ago by Dr. E. E. Hunger of Spencer, upon whose
initiative an enabling act was placed upon your
statutes books which permits the public of any
county to tax themselves for the construction and
maintenance of a community county hospital.
This pioneer work of Dr. Hunger has already
borne fruit by the enactment of similar laws in
other states, and by the practical operation of
these county or community hospitals as health or
diagnostic centers and as the focus of all welfare
work of the community. The leadership of Iowa
is further emphasized by the success obtained by
Dr. E. E. Sampson and his co-workers in estab-
lishing the principle of coordinated and coopera-
tive effort of all local, district and state organiza-
tions engaged in welfare work.
With these fundamental advantages established
in Iowa, your health program should show en-
couraging progress from year to year. This suc-
cess will be insured if organized medicine as ex-
pressed in local, district and state organization
will assume its rightful place in the program. I
say rightful place because organized medicine is
qualified better than any other members of the
public to assume leadership in the program of
community health.
Erroneous Notions
There is an erroneous belief held by members
of the medical profession of some communities
and of some states, that the practice of individual
doctors will be interfered with by programs of
health betterment which are promoted by lay or
semi-medical welfare organizations, or by the
state. We hear and read of social medicine which
some members of the medical profession fear is
to dominate the field of practice. This belief is
erroneous and is beyond the bound of reason.
The most optimistic of us cannot see that the ap-
plication of tried and proved measures of disease
and injury prevention, or the most hoped for cor-
rection of inhygienic conditions, or the greatest
possible improvement of social life will so ma-
terially diminish disease morbidity, or the inci-
dence of injury to a degree that the medical pro-
fession will have nothing to do. Man is too im-
moral or too careless, indifferent and selfish to
permit a millennium of health to occur.
Leadership Logically Medical
Therefore, it behooves us as members of the
medical profession to take the part of leadership
in local, district and state health movements. Let
us medicinize the social movement. That will
help it forward and will place the medical pro-
fession in a position to rationally direct the health
crusade.
44
Journal of Iowa State Medical Society
[February, 1922
To this end, members of the medical profession
should take an interest in, and if necessary, be-
come members of lay welfare organizations,
should secure cooperation of the churches, busi-
ness organizations and members of the com-
munity in the operation of welfare movements
which benefit the public. It lies within the prov-
ince and power of organized medicine of the com-
munity to so shape the public mind that the com-
munity will vote to tax themselves to establish
hospitals and diagnostic centers to be operated by
the community through and by the medical pro-
fession for the benefit of the public. The com-
munity hospital and its one or more diagnostic
centers in the county, or district, will enable the
family physician to practice medicine with greater
efficiency because he may then have all of the
facilities for diagnosis and for treatment at his
command. Under standards fixed by the state
health department public health work may be ef-
ficiently carried on by the medical profession,
aided by the state and county health inspectors
and public health nurses cooperating with local
and state medical and welfare organizations and
with the people of the community.
A Local Program Adapted to Application of Local
Forces in Local Service
The medical profession with a like coopera-
tion with school boards and school teachers will
inspect, give medical care when needed and di-
rect the physical training of the children of the
community. These duties and obligations will in
no way interfere with individual medical prac-
tice. On the other hand, the individual practi-
tioner is aided in his work through the diagnostic
center and hospital to which he has access, and
his own and his family’s well being and happiness
are promoted in common with other members of
the community by this cooperative effort.
I feel greatly honored by the opportunity to ad-
dress this conference composed of earnest men
and women who are so unselfishly engaged in an
effort to benefit their fellow citizens by the im-
provement of the health of the community.
Health is the most valued of all possessions.
When it is lost the money of the richest man in
the world cannot buy it. The most humble and
poorest among us may have it if he will lead a
clean life, at the same time take advantage of the
facilities afforded by the state, by the local, dis-
trict and state medical societies and by other wel-
fare organizations, such as constitute this confer-
ence, to support and aid him in the battle for
health.
X-RAY WORK IN COUNTRY PRACTICE
Charles D. Enfield, M.D., Louisville, Kentucky
It is with the x-ray as a diagnostic aid in the
general practice of medicine in the smaller com-
munities that I propose to deal in this article : to
outline to some extent what may be the factors
which should determine what part the x-ray can
or should play in the diagnostic effort of the
general practitioner in country practice. Most
of the world lives, and most physicians practice,
in communities too small to support a full com-
pany of highly trained workers in the special
fields of medicine, yet in the more prosperous
parts of this country at least, the economic and
cultural status of the population is such that they
demand, and are willing to pay for, a high degree
of professional effort. Our middle western states
especially are dotted with small communities hav-
ing in every sense a modern attitude toward the
things that make for social progress, and yet more
or less remote from the advantages of well or-
ganized clinics, hospitals, or groups. These little
cities have their miles of paving, their city water,
their electric plants and most of the other things
that make life today more comfortable than it
was fifty years ago, yet, in so far as modern med-
icine means specialization of effort, they are,
medically speaking, living in the past. Whether
or not the ultimate solution will be group practice,
with each of the half dozen or dozen physicians
doing the thing for which he is by inclination and
training best fitted, time alone will tell. At pres-
ent such a trend, if existent, is scarcely noticeable.
Lender such circumstances the dictum that the
man who labels himself “physician and surgeon”
must necessarily be neither, cannot apply. The
small town general practitioner has to be not only
physician and surgeon, but ophthalmologist, ob-
stetrician, otologist, pediatrician, and pretty
much ever}'thing else. And he has to cover all
these fields for the simple reason that there is no
one else available to do the work, and it is his
business to give relief wherever it is sought and
in so far as his training and skill permit. It is
usually not a question of whether he can do some
particular piece of work as Avell as the man who
spends his whole time in that particular field.
He is quite ready to admit that he cannot. But is
it preferable that he should do it as well as he
can, or leave it undone? Many a more or less
technical procedure which in the larger city it
would be decidedly culpable for the general prac-
titioner to attempt, since more expert hands are
readily available, in the rural districts it would be
VoL. XII, No. 2]
Journal of Iowa State Medical Society
45
almost equally culpable for him not to proceed
with to the best of his ability. It is only when he
fails to seek available expert consultation, only
when he refuses to give his patient the best skill
that the circumstances and the community offer,
that the general practitioner errs in infringing on
the fields of his various specially trained col-
leagues.
It is in this light that I wish to consider of what
use the x-ray may be to the rural general practi-
tioner. Granting that it is neither desirable nor
practical for him to acquire the technical skill,
the special knowledge, nor the expensive equip-
ment of the qualified roentgenologist, will the ad-
ditional information that he can derive from his
own more modest roentgen investigations justify
the necessary expenditure of time, effort and
money? Will his own roentgengrams of fracture
cases give him sufficiently better results, and
enough additional protection, medico-legally, to
make it worth while ? Will they add enough to his
insight into obscure lung lesions, gastrointestinal
cases, or focal infections to make it pay? The
field of medicine is already so large, its myriad
ramifications so complex, that most physicians
will be in full sympathy with the despairing plaint
of Cecil Rhodes “So much to do; so little time!”
Before entering upon a new and highly technical
field of medical effort, it will pay to consider
well what it has to offer in return for the neces-
sar)' outlays. It may not be out of place to men-
tion that the opinions here offered are based very
largely on an intimate personal experience under
exactly the conditions outlined.
In the first place, advances of very recent
years in the design and manufacture of x-ray
equipment, largely the result of the necessity for
a compact, reliable, and simple equipment for war
purposes, have made technically possible, the pro-
duction of high grade roentgengrams, with a rel-
atively simple and modest plant. The use of dou-
ble intensifying screens with films, instead of
plates, has reduced the amount of x-ray energy
necessary for a given photographic result some
60 per cent to 80 per cent. The use of the self-
rectifying radiator type of Coolidge tube, has
made it possible to dispense with the motor driven
rectifying disc or arms in these smaller outfits.
Less cumbersome, more compact, and more effi-
cient design has characterized the post-war pro-
duction of most accessories. It is therefore, pos-
sible to produce photographically excellent roent-
gengrams without any very complicated machin-
ery, without any special wiring, and without other
than the usual 110 volt alternating electric light-
ing current commonly supplied to most service
mains. Thus the problem of equipment, and the
question of mechanical continuity of service have
both been greatly simplified by recent advances in
design and manufacture. This is in large part
due to the untiring efforts of a few remarkable
men to supply the Lmited States Army with a
field x-ray equipment better than any before used.
But the question of equipment, which I have
considered first, would better have been consid-
ered last. It is, fortunately, a comparatively sim-
ple matter to install a workable plant. And that
accomplished, the first two or three years are the
hardest, to paraphrase the cartoonist. The prob-
lem then divides itself into two parts : the purely
technical performance of producing good roent-
gengrams, and the interpretation of these and the
images seen upon the fluoroscopic screen. The
purely photographic part of the technical work is
neither difficult nor complicated. Anyone with
the laboratory training that every physician has
had, can acquire the fundamentals in short order.
It is not as a rule, desirable to entrust the develop-
ment of x-ray films to a photographer, since the
standards that govern the process are so different
than those that obtain in photographic work. An
intelligent office girl, however, can readily learn
enough about the process to turn out uniformly
even, satisfactory work. It may be well to add
that a fairly roomy dark room with some provi-
sion for ventilation, and with adequate equipment,
or perhaps, a little more than what would suffice,
will well repay the added expenditure.
The remainder of the problem is, or should be,
purely medical, and will call for a definite min-
imum of time, study, and effort. I do not believe
that it is any more advisable for a physician to
attempt to interpret x-ray findings and apply his
conclusions in treatment of disease merely be-
cause he owns an x-ray plant, than it would be
for him to start doing laparotomies without pre-
vious training, merely because someone had sold
him an operating equipment. Nor is roentgen in-
terpretating something that can be "picked up,”
any more than any other special medical knowl-
edge; nor even learned from books alone. The
novice had far better, in his own interests and
those of his patients, give up a definite period of
weeks, at the start, to the study of his subject in
some clinic where there is abundant material and
an expert to interpret it. Almost every general
practitioner considers himself capable of inter-
preting a fracture film ; it is only when he hears
the number of perfectly sound deductions a cap-
able roentgenologist will make from inspecting
that same film, that he realizes how superficial,
and often inaccurate, his impressions may be. Yet
46
Journal of Iowa State ]\Iedical Society
[February, 1922
fracture interpretations are as a rule the simplest
of all readings to make. It is necessar}- to see an
abundance of material day after day for a consid-
erable time, and to digest the interpretations, in
order to get a true perspective for later independ-
ent work. I was recently told by a roentgenol-
ogist of several years experience, that he never
spent a day in a certain clinic which handles a
particularly large volume of x-ray work, without
seeing something new and informing. After an
adequate experience of this kind, the physician
can proceed to do much of his own routine roent-
genography, with a wholesome respect for the
limitations of his own knowledge, and a con-
servatism in drawing conclusions bred of experi-
ence. But let me emphasize again, that without
an earnest period of special training, the expendi-
ture for equipment will be worse than thrown
away, and the whole field of roentgenology- will
have gained, in the mind of the physician, and
probably of his friends, an undeserved black eye.
An inspection of the records of a general prac-
tice in such a community as referred to in the be-
ginning of this article, covering a five-year pe-
riod, showed that in about one patient in five the
x-ray played a legitimate part in the diagnosis.
These figures included very- little yvork referred
for this phase of the examination alone, and com-
paratively feyy- patients yvho came in especially for
x-ray examinations. Further, the aim yy-as to
employ this means of diagnosis only yvhen it
seemed likely, or certain, that information yvould
thus be obtained yvhich was ay-ailable through no
other channel. Xo more attempt yvas made to
“push” the x-ray than any other purely- laboratory
procedure, for instance. Each yvas employed
wherey-er it seemed probable that it yvould furnish
a link in the diagnostic chain, and only there, so
it is probable that this is not far from a fair ay-er-
age for practice of this sort. If then, it be con-
ceded that this procedure is capable of giving
definite negative or positiy-e ey-idence obtainable
in no other yvay, in 20 per cent of cases seen, it
must at once class as a very- important procedure.
“X-Ray Diagnosis” is a phrase very- often used,
and very- rarely- iustified. It is usually no more
accurate than “laboratory- diagnosis” or stetho-
scope diagnosis, or percussion diagnosis. There
are a few conditions in which the x-ray and the
x-ray alone suffices to clinch the diagnosis : there
are hundreds in which it gives y-aluable, often in-
dispensible, additional evidence unobtainable from
other sources. And there are otjicr conditions in
yvhich the evidence obtained roentgenologically
mav be arrived at through special investigations
from other angles. To illustrate, the gastroenter-
ologist and the roentgenologist may arrive,
through yvidely different means, at exactly the
same conclusions in regard to a duodenal ulcer.
The rhinologist and the roentgenologist may reach
an identical opinion in a case of infection of the
accessory- sinuses, the surgeon and the roentgen-
ologist may independently make like diagnoses of
a bone tumor. Yet each is supplementary- to the
other, and the roentgenologist can amplify the
knoyvledge that each of the other investigators
has gained in his oyvn yvay. The point here, hoyv-
ey-er, is that the general man yvith x-ray training
can derive from his roentgen findings the infor-
mation necessary to guide him in selecting treat-
ment, or in referring his patient to one more com-
petent than he to handle this particular condition.
There is no need at this late date to enumerate
the diseased conditions both medical and surgical,
in yvhich the roentgen examination contributes an
essential link to the diagnosis. Reference may
hoyvever be made to the importance of stereo-
scopic films of the chest in the diagnosis of tu-
berculosis and other lung conditions. There is
probably no condition of common occurrence in
yvhich more hinges on a prompt and accurate diag-
nosis than pulmonary- tuberculosis. Where a
positive finding may mean the demand for a com-
plete change in the entire mode of life, and often
of the occupation and even the dyvelling place of
the patient, yve cannot afford to neglect any diag-
nostic measure yvhich promises added certainty.
Verj- many conservative yvorkers in this field, not
themselves roentgenologists, give the x-ray find-
ings equal yveight yvith the physical examination.
It is true that carelessly made and loosely inter-
preted films are of little value ; but this may be
said of the same class of physical examination.
Dunham, yvhose yvork in this connection has been
epoch making, feels that the x-ray gives earlier
definite eyddence than the physical examination,
and often earlier than the most careful history.
On the other hand, if it merely confirms the phy-
sical examination it giy-es an added assurance
that is extremely comforting yvhen it comes to
making radical demands as to therapeutic meas-
ures.
Mention of bone radiology- has purposely been
left to the last. It is from the fracture vieyvpoint
that the general practitioner has usually ap-
proached his oyvn x-ray problem. He is already
convinced that he needs the x-ray to secure bet-
ter restoration of anatomical relationships, better
restitution of function, and greater peace ot
mind. Furthermore, he has had it borne in upon
him that he needs it as a measure of personal pro-
tection, and to inspire greater confidence in his
VoL. XII, No. 2]
Journal of Iowa State Medical Society
47
patients. It will no doubt do for him all that he
expects in this connection, but he will be surprised
to find that as time passes the bone work will
loom less and less large in the total of his roentgen
activities. Ten years ago Dr. Bevan said that the
three pre-requisites to the treatment of fractures
were to “have all ones’ property in his wife's
name, to have ample medical insurance, and to
have frequent x-ray examinations.” Perhaps with
good surgery the first two might today be
omitted.
From the aspect of financial return the same
thing may be said of roentgenology^ that might be
said of any other attempt to enlarge the scope and
increase the accuracy of diagnostic effort. If the
work is taken up earnestly and applied honestly
and intelligently it will prove remunerative in di-
rect proportion to the skill and ability that is put
into it. However the entirely exaggerated respect
in which the general public holds the x-ray as a
diagnostic procedure, will as a rule, make it far
easier to place it on a dividend paying basis than
would otherwise be the case. Indeed, this often
constitutes an embarrassment to the small town
roentgenologist, as patients come to him with an
expressed desire for an x-ray examination in con-
ditions in which it could not possibly play any
useful part. Any mention of the therapeutic use
of the roentgen rays has purposely been omitted.
The field of treatment is a large one, and is con-
stantly growing larger and more important, but
only the superficial type of therapeutic applica-
tion would be within the scope of the sort of ap-
paratus here described, and the whole subject is
one into which it behooves the novice to enter
with exceeding circumspection. The treatment
ray still carries potent possibilities of damage as
well as of immense benefit, and the margin of
safety is small enough that it requires a special
training and experience to avoid using, on the one
hand, an inadequate and useless dose, or, on the
other hand, a harmful and destructive one. It is
quite likely that any general practitioner who se-
riously takes up x-ray work in his own practice
will eventually do a considerable amount of treat-
ment, but it will be as well to defer it until at least
a good working knowledge is gained of the diag-
nostic side.
Summary
1. The general practitioner in the small com-
munity is handicapped in many respects through
lack of expert roentgen consultation and advice.
2. Developments of the past few years in
roentgen appliances and technic have greatly sim-
plified the processes attendant upon the produc-
tion of good roentgengrams.
3. With adequate training it is possible and
profitable for the general practitioner so situated
to do much of his own x-ray work, at least in the
diagnostic application.
4. The attempt to interpret roentgen findings
without adequate training will lead only to dis-
satisfaction and failure.
TREATMENT OF DIABETES*
Edwin B. Winnett, M.D., Des Moines
The treatment of diabetes as I see it today, is
based on the ideas of Dr. Allen : “That of starva-
tion or fasting.” The usual diabetic can make
progress with the disease in no other way, es-
pecially if other than the mild type.
From time to time various modifications of
this plan of treatment have been advocated, be-
cause a large percentage, in fact most of tlie
diabetics do not need to undergo the prolonged
strenuous fast, with the subsequent loss of
strength and weight in order to get sugar free.
It is hard to convince patients of the severe type
that they are better when they loose considerable
of their weight and therefore be able to utilize
more food and to feel better.
Complete laborator}^ data at the start gives the
key to the whole situation. If this is not had it
is better not to undertake any form of treatment,
as you will not get results with the patient and
may do them a great deal of harm.
In the treatment, the first step is a careful his-
tory, and a complete physical examination, in-
cluding blood examinations. IMany of these cases
are complicated by tuberculosis ; by carcinoma of
the head of the pancreas; by chronic infections,
and may be complicated by any of the ills man-
kind falls heir to.
We must correlate all of the different forms of
treatment. Each patient must be treated as an
individual case. We can no more follow the diet
lists as outlined in a book than we can perform
a laporotomy, find the same condition in each
abdomen and treat it in exactly the same way.
One patient can take a great deal more carbohy-
drate with the same amount of protein and fat
than another. The next patient can take little
carbohydrate with a great deal of fat without
causing trouble.
We must also keep in mind that diabetes can
be made worse by treatment. Some should not
have their diet changed. Others may be thrown
into coma by changing the diet too rapidly. Es-
‘Presented at the Polk County Medical Society.
48
Journal of Iowa State Medical Society
[February, 1922
pecially is this true with the patient having had
the disease some time and the diet changed to the
high fat, high protein content or complicated by
an acute infection. Many left handed forms of
treatment are advocated. Such as the various
forms of cure alls ; the drinking of a tea made
from the smut of corn; the use of many and va-
rious drugs. These may have been of benefit, as
I have had no experience with them I cannot say
as to their merits. The general treatment carried
out in my' cases has been to try' and give the pa-
tient sufficient food calories in a well balanced
diet so that they may keep at their usual vocation
in life. This amounts to about thirty calories of
food per kilogram body weight, which is less than
is usually eaten, but I find that patients feel bet-
ter and do not loose weight while taking this
amount of food. It has been my experience that
diabetics of all classes do better and feel better
when sugar free, notwithstanding the fact that
many' good men believe that one per cent or less
of sugar in the urine makes no difference. If
a diabetic excreates sugar he must add to his
diet four calories of food for each gram of
sugar lost, to maintain the balance. This does
not take into account the other ill effects of the
daily excreation of sugar.
The difference between a diabetic who is ex-
creating sugar, and one who is not, is the differ-
ence between an individual who feels well, who
has a hopeful attitude toward the disease, who
looks on the bright side of life, and one who is
tired, with little incentive to work, with a lack
of concentration of ideas, and one who has the
neurasthenic’s ideas of life with the periods of
depression.
In treating diabetes we must first thoroughly
understand the principles of dietetics. We must
be able to figure the diet in grams of the protein,
fat and carbohydrate. We must know the food
content of the more common foods eaten before
we can treat the disease successfully, or before
we can hope to retain the respect and cooperation
of our patient, and this we must have. The
food values can be easily remembered with a lit-
tle study along this line.
The diet of the patient varies with the work
they are doing. It also varies with the age and
weight. Early diagnosis is just as important in
treating diabetes as it is in treating tuberculosis.
The patient may be kept in the mild class if
treated early.
Treatment should be planned according to the
stage of the disease — the mild; the moderate;
the severe.
The general form of treatment has been as
follows and is the plan of Dr. Joslin. All long
standing, complicated, obese or the case showing
acid : The first day omit from the diet fat, after
two days of it the protein, next halve the carbo-
hydrate daily, until the patient is taking 30 grams.
Then fast, unless the patient is sugar free before.
In other cases fast at once. Establish a tolerance
for carbohydrate by feeding 5 or 10 grams car-
bohydrate daily until sugar appears in the urine.
Fast again until sugar free. During the fast
allow tea, coffee, clear broth. Agar jelly. Mayon-
naise, bran muffins or cracked coco.
Drop the carbohydrate intake one-third, next
feed protein 15 grams daily until sugar appears
in the urine or until the patient is taking one or
one and one-half grams per kilogram body
weight. Next add fat until the patient ceases to
loose weight or until the required amount of
food is given. Examine the twenty-four hour
specimen of urine daily. The fasting blood sugar
should be read twice a week. The diet must be
arranged to keep it normal.
It is easy to get the usual diabetic sugar free,
but the hard part of the treatment is to keep them
sugar free and still allow them sufficient food
in a well balanced diet to sustain life.
The diabetic should go to school to the doctor;
learn how to measure, weigh, and prepare the
diet ; how to examine the urine ; to know what
to do should sugar appear in the urine; to recog-
nize the symptoms of a threatened acid poisoning;
what to do should they appear. They' should
know, food content so that they may know what
to eat should the usual diet not be available. The
moderate diabetic should be able to eat at any
table and be able to estimate the protein, fat, and
carbohydrate in the food eaten. The management
can be much better carried out in a hospital until
the patient has learned how to manage his own
case.
The ideal treatment is to first establish the
tolerance. Second, establish a follow up system
which keeps the patient under observation and
still does not keep the disease constantly before
the mind of the patient.
The treatment outlined above is a suggestive
form and should not be rigidly followed in ev-
ery case. The urine should be carefully watched
for acetone and diacetic acid. If they appear the
fats should be limited as fats cause the acidosis,
a forerunner of coma. Coma causes more deaths
in diabetes than any other one cause unless it be
tuberculosis. This is the reason many good men
state that all diabetes is tuberculosis. I do not
believe the above statement is true. All diabetics
treated by me that were at all severe had albumen
VoL. XII, No. 2]
Journal of Iowa State Medical Society
49
in the urine which quickly cleared when the
urine became free from sugar and acid. I am
unable to explain this phenomena.
Diabetics should be encouraged to take watei
freely. The severe type should not take the water
cold as it requires energy to cool it to body tem-
perature. A patient who has a tolerance for less
than 20 grams of carbohydrates per day should
have a fast day once a week. Should the toler-
ence be above that amount the diet should be cut
in one-half once a week. In a well balanced diet
the foods which are acid should about balance the
foods which are basic. It is very necessary that
the doctor feeding diabetics should select for his
patient food of such a nature that the acid bal-
ances the basic.
A chart recording daily the amount of urine
voided, specific gravity, sugar and per cent if
present, diacetic acid, acetone, albumen, ammonia,
intake of carbohydrate fat and protein. The
number of calories of food eaten and the weight
of the patient should be kept of each patient.
The patient expects it and has a right to expect it.
With such a chart the doctor and patient can tell
at a glance just what progress the patient is
making.
After the patient has mastered the situation the
chart is kept by them and much interest is mani-
fest by patients comparing charts.
During the treatment should any of the follow-
ing symptoms develope, they should be carefully
investigated. They may mean an acid poisoning
and prompt treatment at this stage will save the
life of the patient.
Nausea or vomiting; increased weakness, ex-
citement or discomfort ; restlessness ; anorexia ;
deep or labored breathing ; drowsiness or the pa-
tient complains of being unusually tired. — Should
the above symptoms manifest themselves the pa-
tient should be put to bed, heat applied about the
body. A normal salt enema should be given at
once. Nervous and mental excitement should be
avoided. One thousand c.c. of water should be
given either by mouth or by rectum. If on ac-
count of vomiting or diarrhea the fluids cannot
be administered in this manner, they can be given
intravenously. One gram of carbohydrate should
be fed children every twenty- four hours. This
may be either grape fruit juice or orange juice.
A nurse who has had experience nursing diabetic
patients is a great addition to the treatment.
Conclusions : Group diabetics as to mild, mod-
erate, or severe. Do not starve all diabetics.
Careful history of each case. Complete physical
examination of each patient. Treat each patient
individually. Follow no diet lists. Change the
diet slowly and know whether the carbohydrate,
the fat or protein is causing the trouble. Know
the symptoms of threatened coma. Know the
treatment of threatened coma.
THE RELATION OF HOSPITAL STAND-
ARDIZATION TO OBSTETRICS*
Mary L. Tinley, M.D., Council Bluffs
With imperfect statistics from which to judge,
those trained in the science of obstetrics are ap-
palled at the result of its application, or art of
obstetrics.
With the record of 8,500 annual direct and
20,000 indirect deaths of mothers, of hundreds of
thousands coming to hospitals each year for re-
lief incident to childbearing, of 3 to 5 per cent
of babes dying and many more infants maimed,
we are roused to the serious need of meeting and
arresting such results.
Gestation, parturition, lactation and involution,
while theoretically physiologic, are so compli-
cated in conduct, we cannot, in the greatest per-
centage of cases, practically so classify them.
Pregnancy has been called a “disease of nine
months’ duration,” and by Barnebus (?) has
been classified as “a test of the integrity of every
structure of the woman’s body.”
In casting about for relief, we meet the same
problems which have blocked progress in the
past. Chief among these is the undying faith of
w'omen “in nature,” and the willingness of mid-
wives to permit or encourage this devotion.
Any other condition in life fraught with so
many annoyances and painful phenomena as ges-
tation, and any condition taxing the integrity and
endurance of the body as does labor, would call
forth the most careful investigation and skillful
guidance.
Lactation, wdth its great problem of infant nu-
trition and with its influence over involution, will
fail, unguided, thereby paying an annual toll of
thousands of lives of babies plus a restricted phy-
sical, mental and moral development of more un-
countable thousands and a resultant restricted
maternal usefulness and happiness because of an
associated sub- or hyperinvolution.
Constant scientific care must surround the
woman, the unborn, and the infant, if we are to
prevent the sorrows incident to reproduction.
The pregnant woman is a problem for the in-
ternist, the parturient for the surgeon, the foetus
and infant for the peiliatrist.
*Presented before the Seventieth Annual Session Iowa State
Medical Society, Des Moines, Iowa, May 11. 12, 13, 1921.
50
Journal of Iowa State Medical Society
[February, 1922
To meet so great responsibilities the obstetri-
cian must have a correct environment in which
to function. This can only be furnished in a hos-
pital. Possibly for many years, as today, a large
percentage of the maternity cases will continue
to be “sacred to the home.”
Distance and inaccessibility of hospitals to the
outlying places, premature and precipitate onset
and completion of labor, seeming maternal in-
ability to leave the supervision of home, etc., will
continue to hold the greatest number of cases at
home.
These cases must be safeguarded if present
conditions are to be improved. Miles away from
a hospital, in the night, babies will continue to
come, with possibly a tried pair of hands of a
well trained obstetrician to meet every emergency.
Possibly a good neighbor may be the only at-
tendant, and the maiming and losses will continue,
for, — “It is the war.” We have always been and
will always be unprepared for some of the con-
flicts.
Education of the people, arousing an interest
other than sentimental in the pregnant, teaching
the possibility of preventing many dangerous con-
ditions ; providing community nurses to cooper-
ate with local obstetricians, bringing each woman
who does not voluntarily seek this supervision,
that she may be thoroughly examined and her
functions repeatedly tested ; uniform pregnancy
records provided to assemble the data of her phy-
sical condition, functionally and organically ; ac-
curate pelvic measurements recorded ; condition,
position, and presentation of the foetus ; an x-ray
picture if need be to confirm or deny gross foetal
abnormality.
The presence or absence of placenta prsevia
determined, as also any severe toxemias ; con-
tracted pelvis, relative or positive ; exostoses,
tumors of the uterus or adnexa, liable to seri-
ously complicate the exit of the child.
Repeated urinalysis and blood analysis as indi-
cated, both ante- and post-partum. Maternal
blood-pressure repeatedly noted as also foetal and
maternal heart action.
Accurate history, family and personal, should
be considered; also regulation as far as possible
of the environment, food, clothes, rest, etc., of the
mother.
With accurate and uniform supervision of
pregnancy, surprises and unpreparedness in labor
will be lessened.
Careful charting of the various acts of labor
leads to closer study of the individual case.
There should be notation of injuries to mother
and babe, immediate reparation in the best possi-
ble way, and careful examination a few weeks
(6 or 8) later, to determine results, and then plans
for further correction at a suitable time if neces-
sary.
In the past much of the hospital care was but
little, if any, better than that given in the ordinary
home.
With the hospital standardization movement as
inaugurated a year and a half ago, the science and
art of obstetrics, as every other department of
medicine and surgery, will gradually present
greatly improved results.
A fully equipped, well managed hospital, under
central supervision that will demand the most
skilled care for every case entrusted to its staff-,
will surely produce results that will progressively
improve, and be uniform for good throughout the
country.
Internes and nurses trained in such hospitals,
going out into the various communities, will bring
with them the same accurate methods of diagnosis
and skilled prophylaxis and treatment as used in
the hospitals from which they came. Through
these as also the hospitals the people will be ac-
customed to expect and demand the care that in
the coming decade should rob reproduction of a
large percentage of its dangers and disasters, and
reduce the morbidity and mortality of mothers
and babes, as in the past two and one-half de-
cades specific medication has reduced losses from
diphtheria, and correct surgical procedures the
toll of acute appendicitis.
HIGHMORIAN EMPYEMA*
Erank L. Secoy, M.S., M.D., Sioux City
The object of this paper is the report of a cou-
ple of rather obscure cases of maxillary empyema.
I will preface this report with a short outline of
the classification, diagnosis, and treatment of this
malady.
Highmorian empyema usually falls under one
of the three following heads :
A. Acute closed empyema.
B. Acute open empyema.
C. Chronic empyema.
We are all more or less familiar with the acute
closed type, for that is the type we see in extreme
agony with the pain localized definitely over the
antrum involved.
Not so easily recognized is the second type, the
acute open empyema. In fact, this type depends
for recognition largely upon the patient’s own
*Read March 29, 1921 at the fortnightly meeting of the Wood-
bury County Medical Society.
VoL. XII, No. 2]
Journal of Iowa State Medical Society
51
sense of personal comfort, and if he is easily sat-
isfied with a little yellowish discharge and a little
sense of stuffiness in his nose he will not consult
his physician during this stage ; on the other hand,
if he is not satisfied he comes in and the diagnosis
is soon made.
If we are to rely upon our patient for the diag-
nosis in the last class, chronic empyema, as wc
have in the preceding classes, then we are often
led astray. For it is in this group of cases most
of the mistakes are made.
The patient does not complain of a unilateral
discharge so much as he does of frontal headache,
terrific at times and almost gone at others; of a
peculiar burning, smarting pain around the eyes
causing sudden severe unexplained lachrimation ;
of heavy dull aches apparently originating at any
place, but over the site of the involved antrum.
It is this extreme frontal pain coupled with
marked tenderness over the floor of the frontal
sinus that is so often mistaken for a true frontal
sinusitis and opened up only to reveal a per-
fectly nonnal sinus with a consequent continu-
ation of the patient’s frontal symptoms unabated.
As to the diagnosis. That should be relatively
simple, and I believe is, if we will follow a
definite routine and not allow any deviation from
the beaten path. First, have the patient tell his
own story with as little prompting as possible.
Often during this story items very diagnostic will
present themselves which would never have come
to the surface if only stereotyped questions had
been asked. Supposing there is nothing in the
history to indicate antrum disease, then we pro-
ceed to look the patient over. First the outside
of the face and then the inside of the nose, look-
ing here for some chance swelling or edema of
some turbinate or the presence of pus. Suppos-
ing we find a perfectly normal looking nose both
inside and out even after shrinking the turbinates
and applying suction, then we are most apt to
push the transilluminator aside and do a refrac-
tion or something else and miss the pathology.
But supposing we do use the transilluminator
and find the light does not penetrate either side
very readily we are now on a warm trail. The
next step in the diagnosis is the radiogram. It
is more penetrating than transillumination and
consequently may rule out one antrum even after
both were positive with the former instrument.
This is still not the absolute diagnostic test. We
next and finally make use of the antrum punc-
ture. A short needle is thrust through the an-
tral wall under the lower turbinate and clear
sterile water is forced on through this sinus.
The washings are caught in a basin, and if there
is pus inside, you will see it in the pan. If it is
impossible to get water through under ordinary
pressure, intra-antral polyps or other pathology
is sure to exist. The results of this test make the
diagnosis final and absolute. You are inclined
to ask why all this. If a patient does not tran-
silluminate well why not puncture immediately,
or if an antrum is suspected why not puncture
without all these intermediate steps? I can say
that there are times when the radiogram is more
sensitive than the transilluminator and reveals
normal, or at least clear antra, thus saving the
patient the puncture operation. I would secondly
call your attention to the fact that recently a
few eminent Swedish doctors have reported a
large series of sudden deaths occurring in their
offices from the simple antrum puncture; conse-
quently, I do not care to subject the patient to this
operation unless every other indication points di-
rectly towards it ; neither do I want to operate
upon antra which the transilluminator and radio-
graphic plate condemn, and find them normal.
Treatment — Under this heading may be written
chapters and then have few agree with you, con-
sequently, I am only going to give you a general
outline of the essentials.
There are numerous names attached to numer-
ous operations upon the antrum and most of them
depend upon whether a certain operator took
half a bite more of bone posteriorly than the next
man, or whether another individual took two
bites more out anteriorly than did his prede-
cessor, consequently, I am not giving you any
named operations.
The treatment of antrum empyema depends
first of all upon the removal of the pus, and if
that can be done and allow the mucous mem-
brane to regenerate through the simple antrum
puncture, repeated a few times, that procedure is
then sufficient for that case; if this is not enough
the antro-meatal operation is done. This con-
sists of lifting the lower turbinate out of the way,
removing the entire antro-meatal wall from un-
der this turbinate, cleaning out diseased tissue
which may be in the antrum through this opening,
and replacing the lower turbinate over the open-
ing, thus leaving a functionally normal nose be-
hind. The antrum is flushed out daily until
healed.
And lastly the radical or external operation is
done when the intra-antral pathology appears to
be so chronic that actual bone necrosis has taken
place. This procedure begins with an incision ex-
tending along the upper border of the roots of
the upper lateral teeth. The external antral wall
is removed and the entire contents of the sinus
52
Journal of Iowa State Medical Society
[February, 1922
removed under direct inspection. The nasal wall
is handled the same as in the antro-meatal oper-
ation and the periosteum and mucous membrane
of the external wall closed by interrupted silk
sutures and the usual irrigation treatment car-
ried on through the nose until healing takes place
Case Reports
Case 1. G. A., male, aged forty-one, laborer, ex-
amined September 22, 1920. Family history, unim-
portant.
Personal History — In January, 1919, patient had a
“burning, aching pain” over right frontal region
which came on suddenly following the “flu.” This
pain continued severe at intervals until the follow-
ing February when he had the external frontal oper-
ation done. Patient was never free from pain, but
during quiet intervals could attend to his work. He
described the pain as being of a “burning, aching,
throbbing character.” When the pain was very se-
vere the right eye would water and the vision be-
come blurred, necessitating laying off work. His
trouble at this time was diagnosed as a right frontal
empyema. The frontal was opened externally. The
wound healed evidently by primary intention, but
the symptoms remained unchanged. Later he was
told he had nothing in his frontal but “neuralgia
pains.” He continued “treatment” until the follow-
ing September when I saw him.
A radiogram was made and reported clear except
right frontal clouding. There was pus found in the
right ethmoid region, otherwise the nose was appar-
ently normal. A right ethmoid exenteration was
done with little relief of the symptoms for a couple
of weeks, then a beginning of the old frontal pain as
severe as formerly. A diagnosis of neuralgia of
supra-orbital nerve was made and an alcohol injec-
tion was done with relief of pain until the nerve
regenerated, when the frontal symptoms again re-
turned. Finally a tentative diagnosis of migraine
was made and the patient referred for a thorough
physical examination and another radiogram.
The physical report was entirely negative. The
radiogram, however, showed a clouded antrum both
sides with the same right frontal clouding. An
antrum puncture was done on both sides. From the
right antrum came a thick organized clot of yellow
pus about the size of the end of one’s thumb. From
the left antrum came a more thin and flocculent pus.
Diagnosis — Highmorian empyema chronic bilat-
eral.
Operation — February 23, 1921. Since he had pre-
viously lost some upper lateral teeth both sides, a
double radical operation was done.
Pathology — Both antra found filled with pus, gran-
ulation tissue and polyps. All this mass removed
from both sides and external wounds sutured with
interrupted silk sutures.
Post-operative History — The next day patient said
his head felt sore but he could not feel any of the old
frontal “burning pain.” A few days later, admitted
that the head felt as it used to feel years ago. Re-
sumed work within a week and has been free from
all pain and distress since.
Case 2. J. W., male, aged fifteen, student in high
school. Referred by Dr. John W. Shuman February
5, 1921, for special examination. Family history, un-
important.
Personal History — Usual number of colds per year
but none of long duration until “last Thanksgiving
he contracted a very severe cold which settled on his
lungs.” Since then he coughed day and night, keep-
ing himself and the rest of the family awake. The
cough was described as dry and harsh, with very
little expectoration. He had lost ten pounds in
weight, was unable to play games on account of
exertion tiring him. His mother and father “were
afraid he had consumption.” Tonsils and adenoids
had been removed a few years prior. At times
breathing through nose was difficult, but at other
times breathed well. There was some nasal dis-
charge during the colds but none during the inter-
vals. No headache or pain anywhere. General phy-
sical examination. Reported by Dr. John W. Shu-
man, negative. Examination of nose. Inspection.
Some pus in left inferior meatus. No swelling or
edema of any turbinate.
Transillumination — No light transmitted through
either antrum.
Radiogram — Both antra shadowed.
Puncture — Both antra yielded solid clotted pus
when irrigated.
Diagnosis — Highmorian empyema chronic bi-
lateral.
Operation — Double antro-meatal done, pus and
heavy granulation tissue found filling both antra.
Post-operative History — First night patient had
considerable pain, but second night he had his first
night’s rest free from cough for past number of
months. The recovery has been uneventful and
free from cough.
Case 3. V. P., male, aged sixty, examined March
2, 1921. Family history, unimportant.
Personal History — Complained of pain over both
frontal areas and bridge of nose so severe he was
unable to sleep nights or work during the day. Con-
tracted a severe cold a few days prior.
Examination — Intra nasal inspection revealed
swollen congested turbinates but no discharge. Tem-
perature 98.6. Shrinking of turbinates with suction
afforded relief but pain returned at night. This con-
tinued three or four days when the transilluminator
revealed “black” antra.
Radiogram — Revealed heavily shadowed antra.
Puncture — A double puncture was done. The
water flowed through both antra very easily and re-
turned perfectly clear. The former treatment was
continued a few days until symptoms cleared and
nothing further has been heard of the case.
Remarks
Case 1. Is interesting because an external
frontal operation was apparently done on symp-
VoL. XII, No. 2]
Journal of Iowa State Medical Society
53
toms. The ethmoid exenteration and supra-
orbital injection I did evidently unnecessarily
upon a possible misinterpretation of a radiogram,
and because I either failed to use or properly in-
terpret the transilluminator.
Case 2. Is interesting because of the very
strong internal medical history it gives and yet
turns out to belong to the field of special surgery.
Case 3. Is interesting because it demonstrates
to us that even with a solid mass of positive in-
formation present we dare not operate upon antra
without the final results of a puncture.
THE OUTLOOK FOR THE FOURTH ERA
OF SURGERY*
Robert T. Morris, F.A.C.S., New York City
(616 Madison Avenue)
The first era of surgery was heroic. Both the
patient and the surgeon required a high degree of
bravery and the technique was based upon empir-
ical formulas. Next came the second or anatomic
era of surgery when the great anatomists entered
the field and allowed surgeons to know ac-
curately about the structures with which they had
to deal. So great was the progress made in the
second era that one of the great teachers of the
time said that surgery had reached its limita-
tions. Nothing more remained for the student of
surgery in the future, excepting to acquire the
knowledge of what was already known, and to
perfect his manual technique. The most remark-
able advance during the days of the anatomic era
consisted in the introduction of anesthesia, some-
thing quite separate and apart from the anatomic
features of the subject.
Then came Pasteur and Lister who introduced
the third or pathologic era of surgery' with our
knowledge of infections. A complete revolution
in the whole field of surgery followed, and the
third era was the one in which the greatest prog-
ress in all history up to that time had occurred.
According to the principles of the third era the
surgeon was to destroy bacteria and their products
by means of his own resources. The physiologic
resources of the patient himself were overlooked,
or at least, were not given important position.
The surgeon in his conscientious efforts to destroy
bacteria, and to remove their products, introduced
two destructive features. The first of these de-
structive features included the employment of
germicides, which injured the defence mechanism
‘Read before the Annual Assembly, Tri-State District Medical
Society, Waterloo, Iowa, October 4, 5, 6, 7, 1920.
of normal tissue, at the same time when they
were destroying bacteria. Surgeons soon became
aware of the importance of this first destructive
phase of the third era, and corrected it by dispos-
ing of germicides which caused injury to normal
tissue cells. The second destructive phase, that of
prolonged operations, and with unnecessarily
large incisions, which led to destructive impulses
being sent into the centers of consciousness of the
patient, is not as yet fully appreciated. Further-
more, the fact that many bacteria fall into a
wound while the surgeon is at work has a very-
distinct meaning. It means that in the course of
prolonged operative work and with large inci-
sions, very many bacteria fall into the wound
from the air and upon structures which are more
or less damaged, with consequent loss of resist-
ance in the course of operative work. Experi-
ments made with culture media in Petri plates ex-
posed in the operating room under the best of
aseptic precautions, showed that culture media
become infected after fifteen minutes of exposure
and sometimes after only a few minutes exposure.
We are now at the beginning of the fourth or
phy'siologic era in surgery-. Wright and Metchni -
koff with their studies of opsonins and of the
protective forces of the individual gave us a
basis upon which we may formulate the princi-
ples of the physiologic era. In this era we are to
give the patient home rule, in other words, we are
to avoid as far as possible long exposure of the
wound to the air, we are to make as small inci-
sions as will suffice for conducting our operative
work, and we are to avoid the handling of struc-
tures as far as possible in order to avert the de-
structive impulses sent to the centers of con-
sciousness of the patient, even when he is thor-
oughly anesthetized, as has been shown by Crile.
One of the features of the third era of surgery
has stood in the way of rapid acceptance of the
principles of the fourth era. When the rubber
glove was introduced it gave us a distinct ad-
vantage in avoidance of carrying bacteria into the
wound by the hands. On the other side of the
question there was a loss of tactile sense on the
part of the surgeon which has led him to make
larger incisions, and to work largely by sight. In
the fourth or physiologic era we are to take into
consideration this feature of the question and we
must get back to the tactus eruditiis of the older
surgeons who, like Tait and Price, had remark-
ably good results. Such good results in fact that
these men were slow to accept teachings relating
to the germ theory of infection. The protective
resources of the individual are truly remarkable
when these resources are demonstrated after
54
Journal of Iowa State Medical Society
[February, 1922
avoidance of shocking methods of surgical tech-
nique.
W'hen surgeons in general come into full appre-
ciation of the importance of the protective re-
sources of the individual, we shall then emerge
into an acceptance of the principles of the fourth
or physiologic era of surger}-, which will make
almost as great a revolution as that which oc-
curred with the introduction of the third era. We
cannot as yet know what the fifth and sixth eras
of surgerj- will mean but doubtless they are forth-
coming.
PYELITIS*
F. V. Hibbs, i\I.D., Carroll
It seems, in many lines of our great work, that
medical achievement must wait upon discovery.
A light was seen burning distantly by Boazzini of
Frankfort in 1806, later by Segalas of Vienna in
1826, and in 1827 by John Fisher of Boston and
in 1853 by Desormeaux of Paris, in 1865 by
Robert Neuman, in 1874 by Grunfeld, but it was
not until 1877 that Dr. Max Nitze of Berlin was
able to comprehend the light in the true sense of
the word and give to the great profession the
original notion of the illuminated cystoscope.
We appreciate the fact that this instrument was
very crude. During its formative period, this
man labored hard to put proper illumination upon
the subject in hand. We appreciate the fact that
the platinum wire of this primitive instrument
was a great drawback, and a cumbersome thing,
and that this instrument must wait until Roswell
Park of Buffalo came forward with the support
of Edison, and the modern incandescent lamp
was made use of to illuminate the distal end of
the modem cystoscope. Since that time many
changes have been made, but the original idea or
Boazzini was the one that gave Edison the idea,
and his great master mind opened the avenue of
accurate diagnosis of the bladder, of the ureters,
and the kidneys by the aid of this instrument.
Before the days of the cystoscope, the subject of
pyelitis, as a working subject was impractical.
It was impossible to know definitely that we had
a pyelitis. The condition had been discovered
many times at autopsy but was thought to have
been due to an infection from the kidney. For
some reason few men are interested in the work
of the cystoscope and its results. Without the
use of the cystoscope, the accurate diagnosis of
•Presented before the Seventieth Annual Session Iowa State
Medical Society, Des Moines, Iowa, May 11, 12, 13, 1921.
Read by O, C. Morrison.
pyelitis is practically impossible. The clinical
symptoms are fairly well marked, and I believe
there is sufficient evidence to guide us as a work-
ing basis, but to be absolutely sure, we must make
use of the ureteral catheter.
The subject of pyelitis is one which should in-
terest every practitioner. Every general practi-
tioner is brought face to face with some phase of
pyelitis. It may be that he has overlooked this
disease ; has failed to recognize the symptoms, or
has offered some other diagnosis instead of
pyelitis. Every one of you have seen many cases
of pregnancy. Some of you have lost cases of
pregnancy. DeLee says that two-thirds of the
women who die during pregnancy, show evidence
that they either have, or have had pyelitis. It is
a very common disease in children. Girls under
three furnish us a large per cent of our total of
pyelitis in the female, according to the statistics
of today. It is very often found in the male child
and is not uncommon in the male adult.
We have two modes of infection ; the first, the
ascending type, or the type that comes by con-
tinuity of tissue spreading over the mucous mem-
brane, through the urethra and bladder and by
way of the ureter to the kidney. The other is
through the avenue of the blood. This type comes
by way of elimination or by direct metastasis. It
has been pointed out that the female is more prone
to infection than the male for the reason that the
bladder is more easily infected, is more subject to
traumatism. It renders this mode of infection
more common. As the work proceeds in the in-
vestigation of pyelitis, it is found that the male is
coming up with his share of the infection. In the
past it has been overlooked because we have not
made free use of the cystoscope. It is now found
to be possible and practical to cystoscope children
even under one year, and the work is proving of
unusual interest. The men who are interested in
this work, find that the infection in the bladder,
ascending into the ureters, without some mechan-
ical obstruction to the outflow of the urine is very
rare. It is believed that the conunon origin is
from the blood, the lymph or by metastasis.
Pyelitis may be found associated with the ob-
struction of the ureters by tumors or due to an
hypertrophied prostate gland. I think in most of
these cases the infection is not an infection result-
ing from the ascending type, due to the obstruc-
tion.
Etiology — The bacteria responsible for the
etiology in pyelitis is most commonly the colon
bacillus. Pyelitis may be due to the staphylococ-
cus, streptococcus, gonococcus, pneumococcus,
bacillus typhosis, proteus bacillus. The infection
VoL. XII, No. 2]
Journal of Iowa State Medical Society
55
varies but little with the various types of bacteria,
the bacillus typhosis and the colon bacillus be-
ing those usually found in the chronic types.
Pyelitis is always the result of infection, not ob-
struction. It is seldom a primary infection. It is
a metastasis from a bacterial focus of dissemin-
ation.
Pathology — Payer published a chart showing
the pathology of pyelitis some seventy years ago.
The ulceration of the mucosa, opening the
lymphatics to direct infection from the ulcerated
area, is typical. The pelvis of a normal kidney
has a very thin wall, the mucularis is thin and
the fibrous coat is not heavy. Ulcerations caus-
ing perinephritic abscess by direct continuity, and
by metastasis into the lymph system, are common
in the severe types. Should the pelvis be irreg-
ular and full of pockets, we are confronted by
multiple pathology, rendering the treatment very
difficult if not impossible, as to good results.
Symptomatology — The symptoms vary greatly.
Pyelitis is usually the result of a remote infection
in the body, and comes secondary to a focal infec-
tion elsewhere and when undiscovered the orig-
inal focal infection should be carefully sought. If
the ureters are not obstructed and the kidney
parenchyma is normal, and an ulcerative pyelitis
is present, you can see that the type of bacteria
would largely determine the pathology. If we
have a streptococcus infection, the lymph anil
blood reaction to toxemia would be severe in the
average case. The temperature would be high,
lymphocyte count high, pulse rapid and a typical
picture of septicemia and bacteremia would be
present. This infection would naturally involve
the kidney substance and add to the symptoms its
pathology. Should we bar the symptoms of the
original focal infection and deal with the colon
bacillus in the pelvis of the kidney we would
have a picture of that pathology. Locally ulcer-
ation and lymph congestion, perhaps perforation
of the pelvis and perinephritic abscess, high tem-
perature, a rapid bounding pulse with pain and
tenderness over the kidney involved and with ty
pical urinary findings.
Should the staphylococcus be responsible we
would expect abscess formation and perhaps a
chronic cour.se with many exacerbations. The
symptoms can be as varied and complicated as the
imagination may conceive. The important thing
to remember is that pyelitis is usually secondary
to some distant focus of infection, that it came
by way of the blood stream, that there are ulcers
in the pelvis of the kidney and a bacteremia and
septicemia from this new focus of infection, and
that the temperature, pulse and local signs to-
gether with the primary findings, will guide us in
separating the symptoms from the complications.
There are no so-called typical temperature symp-
toms in pyelitis. The temperature may be 104°
in some cases, in others only a slight elevation and
in still others remitting. The finding of pure
cultures of bacteria in the urine is our surest
guide. Pain in the back or referred to the
lower right quadrant of the abdomen, may be mis-
taken for appendicitis or tubal colic. If the case
is worked out carefully and if needs be, in order
to definitely establish the diagnosis, a cystoscope
is passed and the pelvis of the kidney catheterized,
it is possible to know what we have, and which
side is offending.
Diagnosis — The diagnosis results from taking
a careful history of the onset of the infection,
number of attacks, times urine has contained bac-
teria, temperature and pulse, history of childhood,
if it be an adult, together with the urinary find-
ings. The urine must be collected, by a catheter
in a female, in a clean receptacle. Make a careful
search for bacteria and repeat the search on sev-
eral days as the urine may be free of bacteria for
many days and then recur. Make a plate culture
by centrifuging a fresh specimen and using urine
from the bottom of the tube. If in doubt pass
cystoscope and get condition of bladder for cys-
titis. Pass catheter into pelvis and collect urine.
It may be advisable to fill the pelvis with some
collargol, soda or any substance that will give us
the outline of the kidney pelvis that we may have
a reasonably safe guide as to prognosis, as a
pockety, sacculated, irregular pelvis will not yield
the results that a regular, smooth pelvis will yield.
Differential Diagnosis — Pyelitis must be differ-
entiated from: 1. Abscess of the kidney paren-
chyma. 2. Stone in the kidney pelvis. 3. Stone
in the ureter. 4. .Stricture of the ureter. 5.
Appendicitis. 6. Cystitis. 7. Gall-stones. 8.
Ulcer of the stomach. 9. Ulcer of the duo-
denum. 10. Lumbago. 11. T. B. of the spine.
12. T. B. of the kidney.
1. Abscess may be difficult to differentiate.
It may give great difficulty as it simulates pyelitis
very closely in symptomatology.
2. Stone in the kidney is differentiated by
skiagram. It may help us to know this technique
for taking a picture of a kidney. We usually
use a three and one-half inch spark gap, thirty-
five milli-amperes, six to ten seconds time. We
always use a screen and have the obturator
pressed as close as the patient will permit, and
pointing up and out from the junction of the
ninth costal cartilage and rib. Have the bowels
well cleaned with oil. Practice the patient as to
56
Journal of Iowa State Medical Society
[February, 1922
holding his breath, if he breathes the least bit it
will blur the kidney margin and cut out the detail.
Kidney pictures are best made with the slow,
soft ray.
3. Stones in the ureter are differentiated by
the x-ray and ureteral catheter, soft tip.
4. Stricture of the ureter, by x-ray and
catheter.
5. Appendicitis, by the history and absence of
pus and bacteria in the urine, in the usual case.
May be difficult in some cases.
6. Cystitis, by the use of the cystoscope.
7. Gall-stones and cholecystitis by absence of
urinary findings, in usual case, and history.
8. Ulcer of the stomach, x-ray and urinary
findings.
9. Ulcer of the duodenum, x-ray (ninety-five
per cent will show).
10. Lumbago, history and urinary findings.
11. Pott’s disease, by x-ray of spine and no
urine findings.
12. T. B. of kidney, microscopic finding of
T. B. and guinea pig inoculations and positive
chest.
Complications of two or more of the above
with pyelitis makes it more difficult.
This work must be done carefully. If your
technique is not perfect you are lost before you
start. The urine must be gathered aseptically. A
voided specimen in females is worthless. Every
step is essential, and must be done with the great-
est care if you want accurate results.
Prognosis — It is very important that we know
the histor}-' of the infection preceding the onset of
pyelitis as well as the history of the pyelitis. We
must know the bacteria responsible, and if it is
complicated by stone in the pelvis, etc. We must
know the shape of the pelvis and if it is sac-
culated, or if irregular in contour. If there i-5
obstruction to the outlet of the ureter it will be
prolonged, as we do not get sufficient drainage.
One sees at a glance that the prognosis depends
upon many factors and must be arrived at with
great caution.
Treatment — Since the infection arises from a
focus somewhere outside of the pelvis of the kid-
ney, that focus must be dealt with efficiently to
avoid recurrence. The treatment of the im-
mediate pyelitis involves the use of some disin-
fectant in the urinary stream, urotropin and so-
dium benzoate, hygenic care, rest in bed and
symptomatic treatment. If it does not yield to a
mild form of treatment, it may require lavage of
the pelvis with some non-irritating silver salts
twice a week by the ureteral catheter, or drainage
of the pelvis of the kidney by a lumbar incision.
The treatment of pyelitis is undergoing a rapid
change in character due to our progressive work
in this field.
Case Histories
Case No. 1. Miss A. R., ‘age nine; childhood dis-
eases, no scarlet fever or diphtheria. Entrance com-
plaint, fever and chills. Her initial trouble began at
the age of three by an attack of diarrhea which lasted
three days, following this she had pain in the abdo-
men with a temperature of 104 rapid pulse. Urine
examination was not made at that time. The attend-
ing physician made a diagnosis of indigestion. It
was stated that she had had spells of fever and chills
occasionalB" every few months for the last four
years.
Patient entered the hospital emaciated and anemic.
Red blood cells 2,500,000. White cells 12,000. Urine
loaded with pure cultures of colon bacillus. Diag-
nosis of pyelitis was arrived at and treatment in-
stituted. Patient responded quickly and left the hos-
pital in four weeks and gained ten pounds in the next
ninet}^ days. Was free from bacteria for one year or
until the present time.
Case No. 2. Mrs. C. T., age thirty-one, married,
three children living and well; was six months preg-
nant on admission, -with the following history. En-
trance complaint was fever and chills. Patient had
spells of fever as a child but could get no definite
history. Had been well until a few days before ad-
mission to the hospital. This attack came on by a
chill, temperature of 103, rapid pulse and vomiting.
Urine \vas full of pure cultures of colon bacilli. Red
cells 4,000,000. White cells 10,000. She was placed
upon routine treatment and within two weeks urine
was free from bacteria. Returned for confinement
with urine free and is still free.
Case No. 3. Mrs. E. M., age thirty-seven, house-
wife. Entrance complaint, cervical adenitis, requir-
ing drainage, pregnant eight and one-half months,
loss of two-thirds vision. She had five children alive
and well. She had albumin in urine for four or five
years according to her attending physician, who ad-
mitted her for albuminuric retinitis.
A careful search to know if the child was viable
led us to believe the fetus dead. Her albuminuria
and retinitis had deepened and we decided to empty
the uterus which was done by manual dilatation and
forceps. Fetus dead and had been for some time.
The patient did well for fourteen days. Suddenly
out of a clear sky she had a chill, pulse went to 140,
temperature to 105 and the urine loaded with pure
cultures of staphylococcus. Routine treatment was
instituted and the patient made a fine recovery. Left
the hospital free from bacteria, only a trace of al-
bumin and in excellent condition. She has remained
well now for five months and is able to resume her
usual work.
Resume
A. In patients suffering from pyelitis it is
well to seek for a focus of infection other than
the pelvis of the kidney.
VoL. XII, No. 2]
Journal of Iowa State Medical Society
57
B. Be sure to get a clean specimen of urine
and look for the kind of bacteria causing the
pyelitis.
c. Get the patient to bed and suitable treat-
ment instituted.
D. Follow the case carefully after removal of
all possible sources of infection lest a recurrence
occur.
Discussion
Dr. Frank M. Fuller, Keokuk — Nearly every year
we have a paper on pyelitis, and I think it is well
that we do, for the condition is very common and
easy to recognize if the causative factors are care-
fully looked for. And yet we find continually com-
ing into our work cases which have given a clear his-
tory of pyelitis, the condition has been searched for
and never recognized. And the one thing I am on
the floor for today is to emphasize the fact that we
need to pay more attention to the examination of the
urine in all cases, particularly in children. Dr. Hibbs
has emphasized the fact that a large percentage of
these cases of pyelitis arise in childhood. How
many of us examine, as a routine procedure, the
urine of little children? The fact that in so many
cases of pyelitis the urine has never been examined,
is evidence that we are neglecting this very neces-
sary clinical evidence in connection with examina-
tion of our cases. It is not much trouble to collect
the urine. There are measures for collecting the
urine in infants which we can readily adopt. This
requires more patience, more care, more instruction
of the mother, but the urine can usually be very read-
ily examined. It is very little trouble to centrifuge
urine. If you will drop a drop of the centrifuged
urine on the ordinary blood slide, put your cover-
glass over it and examine it and find an increasing
number of pus cells, you can have a very strong sug-
gestion as to what to look for in that case. It does
not take much trouble, and I believe that one of the
things we come here for is to improve the technic of
our work, thus improving the value of our service to
patients. And if there is one thing that this paper
ought to emphasize to this Society, as should be em-
phasized from year to year by the representation of
these papers, it is a more careful, thorough examina-
tion of the urine of patients who are showing atypical
conditions in those cases which are ordinarily and in a
slipshod way diagnosed in children as a gastro-intes-
tinal disturbance. And let me say this; That not-
withstanding the fact that many children do suffer
from repeated gastro-intestinal disturbances due to
the improper hygiene of their food, yet it is a great
mistake for us to assume, because a large number of
children suffer from repeated and constantly recur-
ring gastro-intestinal disturbances, that all of them
that come before us are suffering from this condi-
tion, because we will find on more careful and thor-
ough examination that a certain very positive and
definite percentage of these cases are pyelitis, neglect
of which on our part ofttimes condemns these pa-
tients to a chronic pelvic kidney condition.
Dr. J. E. Dyson, Des Moines — The fact that so
many of these cases appear in infants and children
gives me excuse for appearing on the floor. I wish
to emphasize the appeal for routine examination of
the urine of infants and children. A very simple
method as Dr. Fuller emphasized, is to put a drop of
uncentrifuged urine into the blood-counting cham-
ber, examining it for pus cells in clumps or singly,
and for bacteria. In the fresh specimen we will find
true bacteriauria of colon bacilli. It seems to me there
are two types of pyelitis hitherto unemphasized;
one the pyelitis of childhood, the other of infancy.
These are distinctly separate. The pyelitis of in-
fancy, barring that due to malformations of the kid-
ney and ureters, is most often intestinal in origin; it
is due to the intestinal disturbances of infancy, to
contamination of the genitals, and the increased
lymphatic drainage of the pelvis. Treatment of the
pyelitis of infancy is different from that of the
pyelitis of childhood. The pyelitis of infancy is al-
most entirely a colon bacillus infection that will re-
spond to flushing the kidney with an increased
amount of water by mouth, regulating the bowels,
and alkalinizing the urine. Potassium citrate or
sodium bicarbonate will alkalinize the urine. We
know that the colon bacillus does not grow in an
alkaline medium, but that it grows and flourishes in
an acid medium. The pyelitis of childhood is a dis-
tinct disease and may or may not follow the pyelitis
of infancy. It is due to the acute infections, as mea-
sles, scarlet fever, diphtheria, tonsillitis, etc. It is
often due to metastatic infections from abscessed
teeth and tonsils. A great many of these are colon
infections, but some are due to the streptococcus.
Many of them are staphylococcus and proteus in-
fections. As to treatment of the pyelitis of child-
hood, the condition does not respond to alkaliniza-
tion of the urine. A urinary antiseptic as urotropin,
guaiacol or salol is of more value. However I do
not know just how effective urotropin is, as gener-
ally used in these cases, because it takes quite a bit
of it to cause enough formaldehyd to be formed in
the kidney to kill the colon bacillus. It requires
more urotropin than we ordinarily give to a child;
it requires more than we can give to an infant be-
cause, in large doses it will cause a vesicular irrita-
tion and blood will appear in the urine before suffi-
cient formaldehyd is released to kill the colon bacil-
lus. Absolute rest in bed, and forced fluids goes a
long way in clearing up an acute case of pyelitis, and
removing the septic foci of infection removes the
cause of many chronic cases. I think we should
hesitate to cystoscope infants promiscuously. We
can usually diagnose these cases without a cysto-
scope. There will be considerable trauma to the del-
icate mucous membranes, which are already inflamed
by the disease, even when performed by the most
capable cystoscopist. We do know that there are
some cases of pyelitis in childhood in which there
is a sacular condition of the kidney pelvis forming
pockets, in which cystoscopy and lavage with silver
nitrate or other antiseptic will do some good.
58
Journal of Iowa State Medical Society
[February, 1922
UNUSUAL INDICATION FOR CESAREAN
SECTION— CASE REPORT*
A. B. Deering, I'lI.D., F.A.C.S., Boone
Since the time of mythical deli\ery of Caesar
by section the operation which bears his name has
grown in popularity, slowly at first, but rapidly in
recent years.
I recall that during my student days a Cesarean
Section was a real event. Today it is so common
as to scarcely arouse comment outside the im-
mediate family of the patient.
It is a God-sent boon to many a tortured woman
in the midst of travail, but like some other bless-
ings, its misuse may make of it a curse.
The obstetricians are holding up their hands in
horror at the alarming increase in the number of
Caesarean Sections being done, claiming this op-
eration is seized upon by the unscrupulous and
the untrained as the easiest way out of every ob-
stetric difficult}-.
Admittedly some women have been sectioned
who might better have been delivered by other
methods. But I believe that for ever}- Cesarean
Section done unnecessarily there have been two
cases that had better have been so delivered,
where high forceps or other difficult obstetric
operation has been done to the detriment of
mother or child or both. !Many times the choice
of delivery is one that requires our very best
judgment.
M’ith improved technique Cesarean Section
bids fair to supplant high forceps in the vast ma-
jority of cases. In well selected cases the ma-
ternal mortality of the former is but little greater
than that of the latter, the morbidity is less, and
the fetal mortality is incomparably less.
The time has passed when Cesarean Section
will be reserved for contracted pelvis. No longer
is it possible to lay down absolute indications for
this operation, and say that no woman who does
not come within those indications is entitled to
its benefits. The indications have been broadened
to include all cases where the best interest of
mother and child will be conserved, giving prefer-
ence always to the mother.
Among the many indications for which this
operation is now done are contracted or deformed
pelvis ; disproportion between the size of the head,
and that of the pelvis: any obstruction in the
birth canal, such as tumor or scar tissue: (pla-
centa praevia) abruptio placenta; eclampsia; se-
vere heart and kidney disease.
Of the four Cesarean Sections we have done
•Presented before the Seventieth Annual Session Iowa State
Medical Society, Des Moines, Iowa, May 11, 12, 13, 1921.
in the last six months one was for contracted
pelvis, one for disproportion between the size of
the fetal head and the maternal pelvis, one for
placenta praevia in a woman with a decided hem-
orrhagic tendency, and one for severe nephritis
of pregnancy.
This latter patient complained of increasing
headache, dyspnoea and dimness of vision, had a
systolic blood-pressure of 200, and urine loaded
with albumin casts, and red blood cells.
Cesarean Section was done two weeks before
full term. She now has a healthy child, and her
symptoms have entirely disappeared.
Among the contra-indications to be considered
are dead or deformed fetus, history of repeated
vaginal examinations or examinations made with-
out proper aseptic precautions, previous attempts
at vaginal delivery, long continued and exhausting
labor, rupture of the membrane a long time pre-
vious to the proposed section. Gonorrheal infec-
tion is an important contra-indication. All of
these are more or less relative.
In choosing the mode of delivery in any serious
obstetrical complication the skill and experience
of the operator must be taken into consideration.
This may be the deciding factor in a given case.
Of the three distinct types of abdominal Cesa-
rean Section the Porro operation, in which the
uterus is removed, is not often employed except
when uterine tumors or recognized infection
exist. The Latzko operation with its low ab-
dominal incision, and extra peritoneal opening o£
the uterus is considered safer when we have rea-
son to suspect infection but is a more difficult
operation to perform.
The classic transperitoneal operation, which Is
a very simple one, will probably continue to be
the operation of choice in the majority of cases.
A procedure which I consider of value in con-
nection with this operation is the removal of all
fluid from the uterus by means of a suction ap-
paratus, before the membranes are widely opened.
This is done in order to lessen the danger of soil-
ing the peritoneum.
Post-operative ileus is a complication we have
found most frequent, most annoying. DeLee’s
method of turning the patient on her stomach
with rectal tube inserted, and the foot of the bed
elevated, is often of service in relieving this.
The following rather unusual case is my excuse
for this brief report.
Mrs. Z., para II, aged thirty, entered the hospital
September 3, 1919, in labor at full term. Patient had
always enjoyed good health, heart and kidneys neg-
ative. Has slightly contracted pelvis.
VoL. XII, No. 2]
Journal of Iowa State Medical Society
59
Just two years before I had delivered her of a nine
pound boy by a rather difficult high forceps opera-
tion.
For three weeks previous to her admission Mrs. Z.
had suffered from hay fever and asthma. For five
days she had had a severe cough.
On admission she was having pains fairly regu-
larly, every five to six minutes. And every uterine
contraction brought on a severe paroxysm of cough-
ing, very similar to the paroxysms of whooping
cough. This cough, with which she would choke and
frequently vomit, rendered her pains quite inef-
fectual.
Vaginal examination at this time showed the head
not engaged, cervix partly effaced.
Hoping that as labor progressed her pains would
become more effective, I left her to her nurse and
her cough, for which I prescribed a sedative.
A rectal examination at the end of twenty-four
hours showed the head still riding on the brim of
the pelvis, os still undilated. Pains were now every
three minutes, and still accompanied by that awful
cough. The patient was beginning to show the ef-
fect of her prolonged struggle. It was evident some
method of delivery must be effected to save mother
and child: Either a forced dilatation, followed by
high forceps with its high fetal mortality, a vaginal
Cesarian Section, or an abdominal. Believing the
latter offered an easier and equally safe delivery to
the mother and much brighter prospects for the
child, I proposed this course to the patient who was
glad to accept anything that promised relief from
her pain and cough.
Under gas and ether which she took very well, a
transperitoneal section was done. Before opening
the uterus the tubes were sectioned, and the ends
buried in the broad ligaments.
A nine pound girl was delivered through an in-
cision in the anterior uterine wall and the uterus and
abdomen closed in the usual way.
The mother made an uneventful recovery. She
told me a few days ago that she had never been so
well before in her life. And her babe is the picture
of health.
Discussion
Dr. J. F. Herrick, Ottumwa — When I began to
practice. Cesarean Section was comparative! j’ rare;
now it is comparatively frequent. From his paper
we may judge that Dr. Deering has been conservative
and yet safe. I feel that the experienced obstetrician
of the great hospitals ofttimes successfully deliver a
patient that the ordinary physician could not deliver,
and it may be left to him to deliver by the usual
route. However, in a certain class of cases where
he could succeed, the practitioners available may not
succeed, and in this class I believe that Cesarean
Section performed by a general surgeon who may
not perhaps be familiar with obstetrics, may be a
safer procedure than delivery by the normal route.
In one instance, I feel that if I had done Cesarean
Section my results would have been better than they
were. That was in a case of central implantation of
placenta prsvia. I believe that in any case of cen-
tral or nearly central implantation of placenta
praevia, Cessarean Section should be carefully con-
sidered, as in a great many cases it would doubtless
be the safer method of delivery.
Dr. Charles H. Magee, Burlington — I commend the
paper, and simply as a matter of interest wish to re-
late another unique case of Cesarean Section. Some
two years ago I was called to the hospital to see a
peculiar state of affairs: A woman in labor, the ob-
stetrician a young strong fellow, and the presenta-
tion was a breech, he had taken hold of the body and
pulled it away, leaving the head in the uterus, with
two of the vertebrae, the atlas and axis. I tried to
perforate the head by having an assistant steady it
from above, but it turned each time and I was afraid
I would perforate the uterus. So I performed
Cesarean Section and removed the head, against the
recommendation of the reader of the paper never to
perform this operation when very many vaginal ex-
aminations had been made. But I was “up against
it,” according to the old saying. While I can say that
the mother is all right, I cannot say the same of the
child.
Dr. J. S. Weber, Davenport — We have two general
indications for Cesarean Section, the absolute and the
relative. I think that with more conscientious study
and riper experience, the field of relative indications
should be broadened. As Dr. Murphy used to quote,
“Conscience doth make cowards of us all.” We
should not be afraid to go ahead and do what is
right even in the face of untoward circumstances.
During a practice of nineteen years I have delivered
successfully both as to mother and child, six patients
by transperitoneal section. I am sure you cannot
accuse me of being an ultra-enthusiast, for that num-
ber of cases surely denotes conservatism. Referring
to a practical point in Cesarean Section, in the last
two years I used the transverse incision across the
fundus of the uterus. You will find that by this
method delivery is much easier and the uterine in-
cision is then not in line with the abdominal. An
unusual case which will illustrate another indication
was referred to me about two years ago. The patient
was in uremic convulsions which did not respend to
heroic medical treatment. We figured that the
quickest way out of the difficulty was the best on ac-
count of the woman being a primipara and was not
yet in labor. She was delivered successfully by
Cesarean Section. She had uremic amaurosis, and
there was one convulsion after delivery. A practical
point in a prophylactic way is that we can prevent
some types of dystocia in the female by seeing to it
that the diaper in the case of the female infant is not
too tightly applied. We have seen some of the old
practical nurses wrap up an infant almost like an
Indian papoose. If you will take measurements of
the pelvis, you will find that by tight wrapping the
pelvis of an infant you can reduce its diameter about
an inch, and if this is continued you have the begin-
ning of a justo-minor pelvis.
60
Journal of Iowa State Medical Society
[February, 1922
THE ROLE OF THE ALKALINE PHOS-
PHATES IN HEALTH AND DISEASE
J. Henry Dowd, M.D., Buffalo, N. Y.
Genito-Urinary Surgeon Buffalo Hospital, Sisters of Charity;
Mercy and Contagious Hospitals; Consulting at the Emerg-
ency Hospital; A. M. A., N. Y. State Society, Etc.
We must assume that the practice of medicine
in these days is a commercial enterprise ; that is,
after due preparation an individual takes up this
profession as a means of livelihood ; should he nor
be given all honorable chances to make a living
therefrom ?
In practically all commercial lines we find that
competition is the life of trade, so also do we find
a similar condition existing in the medical profes-
sion, and not restricted, for here it exists up to
the one hundred per cent mark.
In commercial life success depends on the line
of goods carried; their display, but above all, on
the amount of printer’s ink used as a means of
advertising their wares. It is true the medical
man can use printer’s ink, but not in the sense of
his brothers in other lines ; he must depend on
medical journals, a medium that does not reach
the public, although the public are the ones that
receive any benefit from his knowledge. That
publicity by such means being liniited to only a
very small number, the average man has but one
way of displaying his ware ; the dissemination of
his knowledge to the public through the results he
may obtain in his practice.
Indexed there are over thirty-five hundred dis-
eases ; comment is unnecessar)% it would be ob-
viously impossible for any one individual to so
thoroughly master the different symptomatology’’
that they could positively differentiate each and
every malady. Therefore, argument seems un-
necessary, the specialist is a person we cannot
well dispense with, and group diagnostic clinics
have an important place.
An important question might arise here ; can
all patients avail themselves of expert knowledge ;
how many of the average daily patients seen at
our offices, and a fair number that may be seen
at their homes, need helpful hands from the out-
side ?
Men specially skilled, even group diagnostic
clinics are located at medical centers; and admit-
ting that the services can be obtained free, can all
reach such centers? It has been said, there is
very mucli truth in the statement, “not over five
to eight per cent of cases need skilled opinion, if
the medical man be fairly possessed with knowl-
edge of his calling.”
The writer will question the remark made some
time ago by a colleague discussing a medical sub-
ject, “The general practitioner is passing away.”
No greater mistake was ever made; the general
practitioner has alw’ays been and always will be
the most luminous satellite in the firmament of
medicine.
Disease of the human subject can be divided
into two classifications : organic and functional.
In the organic there is an underlying anatomical
change present, whereas, in the functional there
is no such condition existing.
In organic disease the symptoms are located at
one or more definite spots ; they are evident to the
naked eye, or quickly made so by slight examina-
tion ; questioning, auscultation, percussion and the
like.
With the functional it is entirely different.
Here the symptoms cover the body like a blanket ;
they are at one place today, at another tomorrow.
These are the cases that throw obscurity into the
medical case and cause the physician to seek
further advice.
We know that there is a constant bodily change
taking place, in fact, we are told by scientists that
there is a complete change of the human body
every seven years. This change is through cel-
lular destruction, but at the same time we find
reconstruction ; the cast off material is being con-
stantly replaced by new.
Elimination of cast off material takes place
through the lungs, skin, bowels and kidneys,
whereas, the intake for reconstruction is fur-
nished from the food and liquids taken by the
mouth. All the processes are by chemical
changes ; the kidneys are the two most important
emunctories ; the urine is the most available ex-
cretion for examination ; what does this fluid
show regarding the daily metabolic change?
We know that the brain is the seat of all life,
the source from which every function, action,
thought or word arises. Of course it is through
the blood stream that nutrition is carried to the
different structures, but this nutrition is delivered
to the blood through a process of digestion and
assimilation, a function that is entirely under con-
trol of the nervous system.
It must be quite clear, if the nervous system is
the seat of all energy and it has a specific nutri-
tion, this nutrition must be supplied in normal
amounts, and it must be used, or it should be in a
similar manner, otherwise something and some-
one must suffer sooner or later.
Looking at the subject in a more simplified
manner, it must be admitted that the underfed
individual cannot be expected to produce the same
amount of manual labor as the well-fed man ; and
the same should hold good as to the overfed; they
VoL. XII, No. 2]
Journal of Iowa State Medical Society
61
become inactive ; their organs do not act normally.
That blood, muscles and bone have a specific
nutrition there is no question; the same may be
said of the nervous system, in fact, it is taught in
physiology that phosphorus, lecithin and nuclein
are the food of the nerve cells. The value of
these elements in the daily life of the individual is
well stated by the sayings of one of the world’s
greatest scientists ; “when all the phosphorus is
taken from the earth, the human race will cease
to exist.”
Phosphorus, lecithin and nuclein are taken from
the food we eat ; they reach the brain where they
perform their function after which the residue is
eliminated as phosphates, and to a great extent by
the urine. Phosphates appear in the urine under
two forms ; the earthy, or calcium and magne-
sium phosphate, and the alkaline, as sodium and
potassium phosphates. The earthy can be found
in freshly passed urine (gives it a greenish hue)
and readily dissolves by acid, or they may appear
on boiling; viewed under the microscope they
resemble saw dust. This form of phosphates may
be dropped from further consideration, for unless
present in marked quantities, when they must be
filtered out, they are of little or no value as an
aid in diagnosis.
The alkaline phosphates, or those that show
nerve metabolism are never seen except after pre-
cipitation ; they appear as crystals, fern shape in
character, and are present in amounts according
to the quantity of nutrition present in the neu-
rones, the quality, and the way it is being used.
(In the original article, “The Phosphatic Index”
the writer has shown the crystals appearing un-
der, A — normal ; B — want of nutrition ; C — preg-
nancy between the third week and end of third
month ; D — oncoming nerve cell degeneration ;
E — great nerve cell irritation, hysteria, etc.)
The phosphatic index, as it is known, is a sim-
ple procedure ; but ten minutes is necessary using
the second urine passed in the morning.
Fill phosphatometer with urine to U, add sol.
U to S (Mag. sulph.. Ammo, chlor., Aq. ammo,
commercial 10 per cent, an ounce of each, water
eight ounces filter and let stand two or more days
before using), shake thoroughly to mix solution
and urine and set aside for ten minutes.
A white precipitate should form at once, in
density according to the amount of phosphates
present, and will sink according to the specific
gravity of the crystals. If it reaches N. P. m
ten minutes in a practically solid mass, no matter
what may be the case under treatment, the nerve
cells as a factor may be eliminated. Where the
precipitate only falls part way, is light and fluffy.
or goes below N. P., nerve cell nutrition is low
(you have an analogous condition to a deficiency
of hemoglobin with a diminished number of red
cells) and must be supplied artificially so that
normal energy may be distributed to the part or
parts involved that are suffering.
Where the precipitate remains above N. P. in
a practically solid mass at the end of ten minutes,
nerve cell irritability is evident. This is almost
pathognomic of all acute nerve conditions, and
especially so in all cases of hysteria or those in-
dividuals bordering on the same. The increased
metabolism (alkaline phosphatic elimination) is
furnished from the reserve, and unless the out
put be checked, the reserve sooner or later will
become depleted and accompanied, as it is always
is, by nerve tire, commonly called neurasthenia
with all its distressing symptoms.
Briefly reported the following cases will show
the remarkably rapid residts that follow the dis-
covery of the true condition :
(These cases were seen in consultation after
weeks to months of treatment with very little if
any result.)
Case A — Mrs. W. For six or eight weeks a most
aggravating cough; various cough remedies had been
used without any apparent result; no tubercle bacilli
could be found. General systemic symptoms: lost
several pounds in weight; insomnia becoming more
marked as time elapsed; more or less pain in differ-
ent parts of the body; that involving the arm and
shoulder was neuritic (brachial); no appetite and a
constant feeling of fatigue. Examination of the
urine showed no pathological condition to exist in-
volving the urinary tracts; phosphatic index 70 per
cent minus (below normal); crystals a deficiency of
nerve cell nutrition. A mixture of phosphorus, can.
ind. and mix vomi, half a teaspoonful in milk half
an hour after meals was advised. Cough ceased
about the fourth day; in two weeks she had gained
five pounds; in four weeks was feeling perfectly well
with an index about 5 per cent minus. (Maybe the
homeopaths are right, phosphorus is a specific in
lung troubles.)
Case B — Miss E, age eighteen. A more deplor-
able condition is seldom met with, although the con-
dition proved to be of a functional nature. For over
a year, in which time she had lost over twenty
pounds in weight, she complained as follows; no ap-
petite, except for candy and like things; marked leu-
corrhea; obstinate constipation; constant backache;
insomnia most distressing; headache and great ex-
haustion; a mitral murmur was found, but no appar-
ent pathological heart condition. Teeth, tonsils and
sinuses had been carefully gone over but strange to
say nothing abnormal was found. Various modes of
1. Phosphorus to be of value as a remedy must be given in
its elementary form, otherwise it is inert. The formula referrc<l
to is made for me by the Richardson Drug Co. of our city, and
contains phosphorus in its free state.
62
Journal of Iowa State Medical Society
[February, 1922
treatment by iron, nux vomica, hyposphosphates and
the like gave no relief; she was sent to consult a skin
specialist of our city on account of the development
of an eruption, which proved to be lichen planus;
the doctor visited, referred her to the writer as to
her general condition.
No organic condition was found, and urinary exam-
ination showed a faint trace of albumin (anemia) ;
great increase of indican (marked intestinal fermen-
tation); crystals of oxalate of lime (defective me-
tabolism); large quantities of vulvar and vaginal
epithelium (desquamation due to leucorrhea); no pus,
casts, blood or other abnormal findings; the phos-
phatic index showed 90 per cent minus. Explaining
the condition found to Dr. Diehl, he advised pre-
scribing for the general condition first and watch re-
sults. The following was advised: Co. mix of phos.
(Dowd) two ounces (to replace the depleted nerve
cells), fl. ex. Valerian one ounce (for nerve cell irri-
tability); res. podoph. grs. 3 for constipation; half
a teaspoonful in milk, half an hour after meals. In
four weeks afterwards this young woman reported as
follows, “Bowels moving regularly; good appetite,
gained six pounds; sleeps well; practically no more
leucorrhea, and the eruption on hands fading rap-
idly.” At the end of two months an examination re-
vealed an index about 15 per cent minus; no al-
bumin; no murmur; had gained fourteen pounds in
weight and skin eruption practically gone.
This case was very clear as to the true condition;
a general systemic involvement in which the skin,
mucous membranes and blood cells were effected
and all due to a want of nerve cell nutrition.
Case C — Mrs. C, married, age thirty-five. More
or less pain involving the whole body at different
times. Never confined to bed, but movement of
joints (ankles, knees and shoulders), caused pain and
movement was more or less retarded, not constantliq
but at times as she termed it. Sleep was much inter-
fered with on account of pain in the shoulder and
arms; as usual with women, she was constipated.
Off and on for some six months she had received
treatment for rheumatism; her teeth and tonsils had
received attention but no relief. Brachial neuritis
was quickly diagnosticated, a slight trace of al-
bumin showed anemia; no heart involvement, al-
though at times it, as she expressed it, “felt as though
wanting to break from its walls so rapid did it beat.”
A phosphatic index was found 80 per cent minus
and the above mentioned mixture advised. In two
weeks she reported as free of pain and feeling fairly
well; she made a perfect recovery. The suckling
bab}' cannot ask for food when it is hungry; it cries.
The nerves cannot speak, their word for hunger is
pain.
We know that it is as uncomfortable to be too
hot as too cold ; in contradistinction to the above
reports, with a low index, the following report
will show an almost similarity of symptoms, }^et
rapid relief from drugs that have an entirely dif-
ferent action as to those mentioned; the cause
was different as shown by the phosphatic index:
^Irs. M, aged thirty-eight. More or less pain of a
neuralgic nature throughout the entire body; she had
suffered for some time from a brachial neuritis in-
volving the right shoulder. Headache was a com-
mon complaint, as she expressed it, “I am ashamed
at the noise (borbor3’gmus, that my stomach makes,
and always when I am out in company;” she was
obstinantly constipated. Complaining of a great deal
of ej'e trouble, for which she had seen different oc-
ulists, she finally consulted Dr. Clemesha who asked
for an index saying he could find nothing the trouble
with the eyes. She informed me she could not sew
nor read for over ten minutes without headaches and
had been unable to attend the theatre or picture show
for several years; the same conditions (headache)
would occur. All sorts of diagnoses had been given;
ptosis of stomach and intestines, also kidney, chronic
appendicitis, with operation advised, but not ac-
cepted. No pathological condition was evident from
the urine; the index was 75 per cent plus with normal
crj’stals, but slightly small.
She was put on bromide of gold and arsenic, ten
drops three times daily in water, increased one drop
a day to twenty. Results were a little slow at first;
she received but little improvement for three weeks
or so, but at the end of six to seven weeks was en-
tirely free of pain and gas formation; bowels were
moving regularlj-; she could read and sew without
an>' headache resulting and had visited a theatre for
the first time in five years without anj" bad results;
she gained five pounds in weight.
Under the same heading, high index, the fol-
lowing case of high blood-pressure accompanying
chronic interstitial nephritis must convince the
most skeptical of the great value of reducing ar-
terial tension when the nerve cells are acting as a
partial cause;
Dr. W. (personal case). Bleeding from the right
nostril, greatU' agitated. Advised to let bleeding
continue, as it was not severe and was possibly an
effort of nature to avert death, or at least apoplexy;
elixir valerinate of ammonia was ordered as a sort
of a sedative, with a request for a sample of urine
for examination; his blood-pressure was 250.
A very few minutes showed serious kidney involve-
ment; lots of albumin and casts showing marked de-
generation; the index was 150 per cent plus. Brom-
ide of gold and arsenic was ordered at once with ad-
vice to at once have careful examination of the
heart, which appeared to be in a very bad condition.
The doctor, although very ill, being confined to his
bed on account of the heart condition, has had no
nose bleeding since and his pressure is 190; the mix-
ture has also appeared to have a most beneficial ac-
tion on the heart muscles, he is quite free from all
symptoms.
VoL. XII, No. 2]
Journal of Iowa State Medical Society
63
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Office of Publication, Des Moines, Iowa
Vol. XII February 15, 1922 No. 2
SCHICK TEST AND ACTIVE IMMUNIZATION
AGAINST DIPHTHERIA
Important papers have recently appeared in
medical journals relating to the Schick test. The
New York Medical Journal for August 17, 1921,
contains an important paper by Schick of Vienna
on this subject. The antitoxin treatment has for
several years been the standard treatment when
the bacteriological examination of throat showed
the diphtheria organism, and “the rule has been
laid down that diphtheria was present whenever
the bacilli were found, and that, on the other
hand, there could be no diphtheria without the
organism.” Schick contends that the rule re-
quires certain modifications. It is a recognized
fact that the causative organisms can be found in
the throat of patients who have already recovered
from the disease; 75 per cent in a state of varying
virulence up to three weeks, and in two per cent
after more than ninety days. Confusion arose
when typical Klebe-Loeffler bacilli were found
in the mucosa of the nose and throat of healthy
persons, who had never suffered from diph-
theria. The presence of the diphtheria bacillus
in healthy throats furnished grounds for an at-
tack on the accepted etiological factors of diph-
theria by those opposed to scientific methods of
diagnosis. The significance of these findings,
was to demonstrate the fundamental resistance
of the body to infection, and except an individual
predisposition was present, infection would not
occur. Investigation has seemed to establish the
fact that carriers acquire the organism by direct
contact with persons actually suffering from
diphtheria or with other carriers. To relieve the
confusion that arises from finding diphtheria
bacilli in the throats of the vast majority of the
population, with no apparent consequences, while
only a comparatively limited number of indi-
viduals, chiefly children, between the ages of one
to five fall victims to the disease, it has been
found that antitoxic substances exist, both in
adults and in infants. “These observations led
to the formation of the axiom that susceptibility
to diphtheria was caused through lack of specific
antibodies. It has been confirmed repeatedly that
these antibodies are absent in children suffering
from diphtheria, and that diphtheria cannot oc-
cur in individuals possessing protective bodies.”
Examinations on a large scale became possible
after a way had been discovered of testing for
the presence of antibodies by means of the inter-
dermal injections of small quantities of toxine,
namely one-fiftieth of the minimum lethal dose
for a guinea pig weighing 250 grams. The fol-
lowing figures are the result of extensive animal
experiments carried out by Greer and Kossowitz
at the Vienna Children’s Clinic. If the skin shows
no reaction to the injection, the result is negative.
In positive cases a sharply defined spot of ery-
themia is noticed with an area of infiltration
possessing a diameter of ten to thirty m.m. A
negative result not only proves the presence of
antibodies, but also excludes the existence of
diphtheria. There are but two exceptions to the
rule; these occur in virulent or septic cases of
diphtheria and in cachectic children. It may be
stated “that the intradermal test may carry more
weight than the result of bacteriological examin-
ation.” “A positive intradermal reaction only
proves the absence of protective bodies” and does
not necessarily signify that the affection present
is diphtheria, and that infection does not always
occur, even if antibodies are absent. This may
be due to mechanical protection derived from in-
tact mucus membrane against bacterial invasion.
This explains why after operations, as removal
of tonsils or adenoids, diphtheria infection fol-
lows in the absence of protective bodies.
In pursuing the subject Schick points out that
most authorities hold that antibodies are the result
of a previous attack of diphtheria. And as it is held
that the presence of antibodies creates an immun-
ity it is interesting to know how long after an
attack the immunity may exist. It has been
shown that the antibodies practically disappear
in a year, and in some cases earlier, as is shown in
repeated attack at comparatively short intervals.
64
Journal of Iowa State Medical Society
[February, 1922
thus it would seem that the antibodies begin to
disappear with convalescence. Schick observes
that cases which manifest symptoms of increasing
severity in successive attacks may be explained
by assuming that the cells had failed to acquire
the faculty of accelerated antitoxine formation.
The significance of Schick’s work is to show
that the bacteriological examinations which we
heretofore relied on, is not to be entirely relied
upon and that in an epidemic of diphtheria the
question of natural or acquired immunity should
be tested by the Schick method.
The practical value of the Schick test has been
accepted by the United States Army. At the
Station Hospital, Coblenz, Germany, under the
direction of Col. F. R. Keefer, IM.C., chief sur-
geon of the American Forces in Germany, the
soldiers have been tested out by the Schick
method with striking results as to immunity.
UNITED STATES PUBLIC HEALTH SERVICE
In this number of the Journal, we are printing
a bill for reorganization of the Public Health
Service which we trust every member will read
with care.
The older members of the medical profession
will remember the fear that came upon us every
summer, particularly in the southern states, on
account of yellow fever. There were the dangers
from travel in the tropics; the difficulties of
trade; the fear of importing dangerous tropical
diseases ; all of which has disappeared but not
permanently unless great watchfulness is ob-
served. \Ye know how to watch and guard
against the danger, but the watchers and guard-
ians must be trained men, devoting their energies
to this one particular thing. Most informed
people know that within the last six years, our
trade in the tropics has increased nearly six
times. We know the value of this increased
trade. We know furthermore, that if watchful-
ness is not observed the dangers are correspond-
ingly increased. Safety is not accomplished auto-
matically but by watchfulness, day and night, and
additional forces must be employed of highly
trained men.
Then consider our own internal affairs; the
various infectious diseases which were at one
time so prevalent, have now almost disappeared,
but are always ready to spring up if there -s
negligent watchfulness.
From all directions come a demand for more
and better trained guardians of public health.
Then there are hundreds of thousands of re-
turned soldiers suffering from various diseases
contracted in the service of our countr}L These
men require, and are entitled, to the services of
trained physicians, surgeons, and specialists, with
the facilities, and means of rendering the best
and most efficient care and treatment. It seems
almost unnecessary to say that this work should
be conducted by trained full time men, whose
training and fitness especially qualify them to
care for the men whose peculiarities and suffer-
ings have rendered them quite different from
communities in general in which most physicians
practice. These men generally believe their dis-
abilities are due to government service for which
they, themselves, have no responsibility. We
have had enough experience with the care and
treatment given by practitioners in private prac-
tice who often have little patience with the pe-
culiarities and demands of ex-soldiers.
WTen we consider all these things, we feel
that the government should provide liberally for
public welfare, which we believe the government
is quite willing to do. But there is danger that
the law makers may make a serious mistake un-
less the right way is pointed out by men who
ought to know.
There must be provided a sufficient number
of medical men to render this service. These
men must be highly trained and compensated suf-
ficiently to make the service attractive. They
must be full time men, who may devote their en-
tire energy" to the conduct of special lines of
work.
The question of compensation is of vital im-
portance. The men needed are the successful
men, men who may earn a larger income than the
government can afford to pay in the form of
salai*}'. They must be placed on the basis of the
regular army service as to rank, promotion, al-
lowance, pay and retirement. If all this is not
provided, the government must depend on the
odds and ends of the medical profession. It is
not only a money consideration that will influ-
ence suitable medical men, but the respectability
of the service. No man the government needs
will accept a service he feels he must apologize
for, but a service which requires a careful train-
ing, and a rigid examination as to qualification
and moral character, that carries rank and pro-
motion. This does not imply a medical aristo-
cracy, but just a self-respecting employment in a
self-respecting government.
If the provisions we have outlined are not
adopted, there will always be a shortage of public
health doctors, made up largely of unsuccessful
and unfit men. If the work is given over to
private doctors the condition will even be worse ;
VoL. XII, No. 2]
Journal of Iowa State Medical Society
65
this we know from personal observation in the
early days of the war risk service, and for many
years’ observations of local health officers.
The service is of such vital importance to the
country, we feel that every physician should use
all his influence with his friends in Congress to
secure the passage of the bill referred to.
THE TRIALS OF BOOK PUBLISHERS
Those who purchase medical books, or sub-
scribe for medical journals, are reminded from
time to time of the expense of medical literature.
The agents of publishing houses complain that
the sale of books is slow, and wonder why it is,
that agents of physicians’ supply houses are flour-
ishing. A little reflection would bring the solu-
tion. The agent of a supply house furnishes a
free lecture on the therapeutic value of the prod-
uct he has to sell, and furnishes without a cost a
handful of literature that sets forth the class of
cases the product will cure, the indications for its
use, and method of administration, all of which
makes the practice of medicine easy and profit-
able, and materially lessens the need of books.
A book agent recently after a day of discourag-
ing canvassing, said that a doctor he called on
stated that he had no need of books because he
attended clinics. In this day of commercialism it
is sad to think that free clinics are destroying the
medical book trade. But it may be that this was
only an isolated instance.
The Hahnenianmian, an excellent journal pub-
lished by the homeopathic medical society of
Pennsylvania, recently issued a circular letter to
the members of the society that the greatly in-
creased cost of publishing the journal would
render the long cherished hope of enlarging the
publication impossible, unless 1,000 new sub-
scribers could be secured, in that event thirty-two
pages could be added. The journal has at pres-
ent 1750 subscribers and publishes sixty-four
pages of reading matter at a subscription price
of $3.00. We sincerely hope that the 1,000 new
names may be secured.
GORGAS MEMORIAL INSTITUTE OF TROPI-
CAL AND PREVENTIVE MEDICINE
To Be Established in Panama
Of particularly deep interest to all members of the
medical profession and to all others interested in
questions of public health and sanitation is the re-
cent announcement of the plans of the board of
directors of the Gorgas Memorial for the establish-
ment of a Memorial Institution in the City of
Panama for research and the extension of means of
prevention of tropical diseases.
Anyone who has seen the old Panama at the time
of the abandonment by the French of the work of
the first canal, involving so much wasted energy, the
loss of thousands of lives and some hundreds of
millions of dollars, could not but be struck with the
present aspect of Panama, its splendid sanitation,
its beautiful cities, its five hospitals, and above all,
by the completion of the Panama Canal itself, mak-
ing Panama one of the most beautiful and salubrious
spots in the world.
It is w'ell known to members of the medical pro-
fession that the accomplishment of this great work
and the sanitary regeneration of Panama are due to
the efforts of the late William C. Gorgas, surgeon
general of the United States Army, and to his ef-
forts, more than to any other, success for the work
must be accredited.
Coupled with his earlier work in Cuba, the ac-
complishment of General Gorgas in conquering yel-
low fever and malaria and conclusively demonstrat-
ing the fact that health, even in the tropics, is a
purchasable commodity has sent forth his fame
throughout the world. Perhaps no single life has
done more for the good and well being of humanity,
and his great attachment for Panama has made the
proposed memorial to carry on the work he so ably
started, the most practical tribute which could be
conceived to his memory.
The honor for the conception of this idea and of
bringing it into actual existence belongs to Dr.
Belisario Porras, the president of the Republic of
Panama, who in the name of his government has
tendered the site, a building, and all required equip-
ment, valued in all at approximately $500,000. At
the request of Dr. Porras, Admiral Braisted, for-
merly surgeon general of the United States Navy,
with the cooperation of others equally interested in
making this memorial possible, incorporated the
Gorgas Memorial Institute for the purpose, in addi-
tion to directing the scientific w-ork, of raising an
endowment fund of five million dollars for mainten-
ance. The following officers and directors were
elected: President, Rear Admiral W. C. Braisted,
U. S. Navy (retired); vice-president. Dr. Franklin
Martin, secretary general, American College of Sur-
geons. Directors: Dr. Belisario Porras, president
of the Republic of Panama (founder); Ur. A. S.
Boyd, chief of surgical service, Santo Tomas Hos-
pital, Panama; Surgeon General Hugh S. Gumming,
United States Public Health Service; Surgeon Gen-
eral Merritt W. Ireland, United States Army; Hon-
orable John Bassett Moore, judge of the Interna-
tional Court of Justice, The League of Nations; Hon-
orable Leo S. Rowe, director general. Pan American
Union; Surgeon General E. R. Stitt, United States
Navy.
Dr. Richard P. Strong of Harvard University,
chosen to head the scientific board, will be assisted
by Admiral E. R. Stitt and Lieutenant Colonel J. F.
66
Journal of Iowa State Medical Society
[February, 1922
Siler. Other members of the scientific board will
be announced at an early date.
The advisory board, of which Secretary of State
Hughes is honorarj'- chairman, consists of the dip-
lomatic representatives of all the Central and South
American countries and representative committees
of the leading national medical and surgical asso-
ciations, public health groups, and many southern
societies by which Gorgas was beloved.
The proposed memorial will be built adjacent to
the new two million dollar Santo Tomas Hospital,
and the use of its complete facilities has been ten-
dered the Gorgas Memorial to aid in the launching
of the work.
The memorial building itself will consist of a dig-
nified classic structure patterned after the lines of
the Pan American Union in Washington, D. C. It
will house the laboratories and provide facilities
for the teaching of students from the various trop-
ical countries and from our own leading schools of
tropical medicine, such as Harvard, Johns Hopkins,
and the University of California.
In commenting upon the field of work before the
Institute, Admiral Braisted stated that among the dis-
eases which will be studied in addition to yellow fever
and malaria, are dengue, pellagra, beriberi, leprosy,
cholera, and the various mj^coses. It is the con-
sensus of opinion that tremendous advances can and
will be made through the efforts of the research
work in this field.
The tropics, which are so prolific in vegetation of
every kind, have been equally fertile in the develop-
ment of all types and kinds of dread diseases, which
tended to make them unsuited and impossible of
habitation until careful sanitation made them safe.
They then can become the most desirable, the most
attractive, and the most prosperous of abiding places.
This verj^ fact has made the City of Panama ex-
tremely desirable as a home for the work to be un-
dertaken.
The humanitarian benefits to accrue from the es-
tablishment of this wonderful tribute to General
Gorgas are almost beyond conception. Its complete
success means the fulfillment of General Gorgas’
greatest desire, that of eliminating these devastating
tropical diseases, and at the same time is a fitting
recognition of the worldwide importance that the
profession of medicine plaj'ed in the construction of
the Panama Canal.
IMMUNOLOGIC EXPERIMENTS WITH
STREPTOCOCCI FROM INFLUENZA
From a study of the effects of iniratracheal in-
jection of green producing streptococci isolated in
influenza and the accompanying pneumonia, we have
found a strain or strains which possess marked and
peculiar virulence. With these, the picture of influ-
enza has been closelj' simulated in animals. A mon-
ovalent serum has been prepared in a horse by the
injection of one strain isolated from the blood in a
fatal case. The agglutinating power of this serum,
type pneumococcus serum, hemolytic streptococcus
serum, and normal horse serum, has been tested
against numerous strains isolated from the sputum,
throat, blood and lung exudate in cases of influenza.
Specific agglutinations with the monovalent serum
have been obtained in a large number of cases of in-
fluenza. The cases studied came from widely sep-
arated communities, most of the negative agglutin-
ations occurring when the cultures were made dur-
ing convalescence. However, this was true in a
few instances in the early part of typical attacks.
This specific strain, according to this test, tends to
disappear promptly during convalescence, and is
rarely found in normal throats. Some of these
strains, just as has been found to be the case with
the streptococcus from poliomyelitis, lose their
specific character promptly on cultivation, while
others remain susceptible to specific agglutination
months after isolation. Most of the specific strains
do not ferment inulin and are not bile soluble. The
agglutination experiments showed that the green-
producing strains of this streptococcus from in-
fluenza are immunologically identical, or closely re-
lated. Single highly agglutinable strains have been
found to absorb the specific agglutinins from the
serum for all the strains. Non-agglutinating strains,
induing Type II pneumococci, remove little or no
agglutinin. According to these tests, therefore, it
appears that among the green-producing streptococci
or diplostreptococci in influenza there is present a
strain that has pandemic characteristics. — E. C. Rose-
now, Rochester, Minnesota, Journal of the American
Medical Association.
INCIDENCE OF PNEUMONIA
In Vaccinated and Unvaccinated Troops from De-
cember 1, 1920 to March 31, 1921, 2nd
Division, Camp Travis
1
PER.SONS
INCIDENCE OF
PNEUMONIA
Number
Per Cent
of Total
Strength
No.
of
Cases
Rate
Per
lOOO
Complete
vaccination
. 840
5.4
0
0
Partial
vaccination
. 526
3.3
0
0
Total vaccination.
. 1366
8.7
0
0.0
Not vaccinated
.14296
91.3
19
1.33
Total average
strength
.15632
100.0
19
1.21
In 1366 completely and partially vaccinated indi-
viduals no case of pneumonia occurred, while in
14296 unvaccinated persons 19 cases were reported
or one in every 752 men. These findings are not
conclusive but they indicate that further work along
this line would probably yield promising results.
VoL. XII, No. 2]
Journal of Iowa State Medical Society
67
Almost 50 per cent of the 17th Field Artillery Reg-
iment was vaccinated but a short time later this regi-
ment was ordered away and the results of this large
number of vaccinations is not obtainable.
Type of Pneumococcus — Of the nineteen cases of
pneumonia which occurred eleven were typed with
the following results: Type I, 2; Type II, I; Type
III, 1; Type IV, 7.
Of all specimens typed, some of which did not
have pneumonia: Type I, 5; Type II, 7; Type III,
3; Type IV, 30.
Conclusions — In order to make a complete apd
trustworthy study of the value of pneumococcus vac-
cination, it will be necessary to have a large number
of vaccinated individuals. This can only be secured
by:
(a) Compulsory vaccination of at least 7,000 men
or approximately one-half of the division. The
present experience indicated that this vaccine causes
no inconvenience and therefore there can be no ob-
jection to its use.
(b) Allowing these regiments to remain at one
location during the time of observation, probably
four months, as approximate!}' 50 per cent of one
regiment was ordered away soon after this study
was undertaken.
(c) Some officer should be detailed to this study
as a special work, as experience has shown that in
no other way can proper results be obtained.
The second division is located at Camp Travis,
Texas and is a separate command. All sick are
transferred to Station Hospital, Fort Sam Houston,
Texas, another separate command. The laboratory
studies are made by the Corps Area Laboratory. Part
of the information on each case must be collected
from each source and involves the cooperation of
some fifty medical officers and a host of non-com-
missioned officers. One man assigned for this work
can secure it all at the source, and such statistics, 'f
they include a large number of cases, will be reliable
and trustworthy. — (Aledico-Military Review.)
BRONCHO-PULMONARY SPIROCHETOSIS
The occurrence of broncho-pulmonary spirocheto-
sis is comparatively rare. This circumstance, to-
gether with the peculiar characteristics of the disease,
makes it a particularly individual problem. The vie
tims of this disease are apparently suffering from
tuberculosis. They have recurring hemoptysis for
months. Usually chronic bronchitis, with loss of
weight, emaciation, and a chronic cough ensue.
Hemorrhages sometimes last for weeks and then
may stop for weeks. These cases are not tubercu-
losis, however, for upon examination of the sputum
no tubercle bacilli are found but large numbers of
motile spirochetes. Bloedorn and Houghton in a
report of three cases found that these organisms are
more refractive and active than the treponema pal-
lida, and that they tended to be of two distinct types.
One type was thin, delicate, and threadlike with
more regular and numerous indulations; the other
type was coarser, with few indulations and heavier
staining.
There has been little investigation made upon this
disease. Castellani first described it in 1906. Since
then there have been reports of cases occurring for
the most part in the tropical climates. It is probable
that the disease is more common in the United
States than is realized, but because of its close symp-
tomatic resemblance to tuberculosis, it is seldom
recognized until the sputum is examined and the
characteristic organism identified. Cases respond to
treatment with the arsphenamins very readily. There
have been cases which when treated for tuberculosis
were considered hopeless but when treated with
arsphenamin, have recovered completely.
In view of the fact that this disease is more preva-
lent than is realized and that it does respond to
treatment, it is important that every case of supposed
tuberculosis that does not show tubercle bacilli in
the sputum should be carefully examined for spir-
ochotosis and syphilis. Prompt and intensive treat-
ment with the arsphenamins may be expected to
produce well-nigh miraculous results.
MEDICAL NEWS NOTES
Public Health Service
A resolution protesting against the plan by which
congress would replace medical reserve officers with
civilian doctors W'as passed January 5, 1922 by former
service men who are confined in the government
reconstruction hospital at Colfax, Iowa.
The resolution, bearing the signatures of ninety-
one disabled soldiers, will be forwarded to President
Harding immediately.
The former service men are opposed to any change
in the staff of the Colfax institution on the grounds
that the reserve officers are familiar with their disa-
bilities and show more interest in the general welfare
of the patients than civilian doctors, according to one
of the hospital officials.
It is said that the attempt to change the physicians
of government hospitals is the work of a group of
politicians in congress who are opposed to the Dyer-
Watson bill, under which reserve officers were to
have been placed on the staffs of the hospitals for a
specified period.
Under the present arrangement physicians at the
Colfax hospital and other government institutions
are being subjected to an injustice, in the opinion of
members of the medical staff at the Colfax recon-
struction hospital, as they have no assurance that
their connections with government institutions will
be permanent.
“We have no future under the present arrange-
ment. We don’t know from one day to the next
whether we will have a position or not,” said one
physician, a member of the medical reserve corps.
The former service men, at their meeting yester-
day, also passed a resolution declaring that in their
68
Journal of Iowa State Medical Society
[February, 1922
opinion the government would be subjected to an
added expense if any change to civilian doctors were
made.
The movement to replace the reserve officers by
civilians has been held up temporarily by congress.
Representatives Ramseyer and Sweet of Iowa con-
ferred with the veterans bureau in Washington yes-
terday, opposing the change. The American Legion
is also protesting against the change. — Des Moines
Register.
IOWA STATE UNIVERSITY NEWS NOTES
Dr. Don M. Griswold
Christmas holidays was a very cheerful time at the
University Hospital and the Children’s Hospital.
Thanks, for much of this Christmas cheer is due to
the many friends about the state who have estab-
lished the custom of sending something for the en-
tertainment of the patients each year. If these
donors could personally see the joy caused by their
thoughtfulness and consideration, they would be re-
paid many times for their interest. Adults received
many gifts of nuts, candies, and cakes; while the
children were bountifully supplied with toj'S, storj'
books, and clothing. Clothing for the children is
always acceptable, for they are frequently brought
to the hospital on stretchers or in their bed clothing,
and when they are well and ready to return, the
problem of furnishing an outfit is quite a serious one.
Each child in the hospital was furnished a liberal
supply of books and toys and a reserve was put away
for the benefit of children who will enter the hos-
pital in the coming months. Several hundred dollars
in money was also received, to be expended by the
superintendent of the hospital for Christmas cheer
for the children. Each ward in the hospital had a
Christmas tree, and usually some hospital attendant
acted as Santa Claus. The nurses showed great
personal interest in the Christmas cheer and vied
with each other in decorating the wards and ar-
ranging informal programs. The children who spent
this Christmas at the hospital will remember it as a
very pleasant memory.
The new nurses’ home on the new medical campus
west of the river was open for occupancy January
first. This dormitory is located on a bluff overlook-
the Iowa river, which makes a delightful location.
It will house 120 nurses, and has a cafeteria in con-
nection. This building will house the pupil nurses
and graduate nurses from the Children’s and the
Psychopathic Hospitals. There is another large
nurses’ home near the University Hospital for pupil
nurses and four smaller homes for the graduate
staff.
The new Psychopathic Hospital which has been
under construction for the past year was opened for
patients, December 19. On that date the patients
and the staff moved from their temporary quarters
to their new building. The new location is just west
of the Children’s Hospital, and is of the same general
type of architecture. The central building contains
the administrative offices, laboratories, class-rooms
and a library. The two wings are equipped to ac-
commodate thirty patients. Each wing is divided
into three wards, which in turn are divided into in-
dividual rooms. Each ward has its own service
room, dining room and prolonged bath room.
There is such a demand for the service rendered
by the Psychopathic Hospital that a waiting list has
already developed and many patients are sent for
study. An out-patient clinic has been instituted and
serves as a diagnostic clinic in cases where the con-
sultation of the staff is desired.
The total staff of the Psychopathic Hospital num-
bers twenty-seven, and includes, beside the usual
medical staff, a psychiatrist, a psychologist, a chem-
ist, a serologist, a social worker, and a nursing staff
especially trained in psychopathic work.
Drs. L. W. Dean, Arthur Steindler and A. H. By-
field, held clinics at Sioux Falls, December 5.
Dr. Merle French, assistant state epidemiologist,
recently performed the Schick test on all the resi-
dents of the Independence State Hospital. The State
Board of Control are anxious to keep diphtheria at
the lowest possible point in state institutions, and are
having this work done at the various places under
their charge.
PUBLIC— NO. 97— 67TH CONGRESS— S. 1039
An Act for the Promotion of the Welfare and Hy-
giene of Maternity and Infancy, and for Other
Purposes
Be it enacted by the Senate and House of Repre-
sentatives of the United States of America in Con-
gress assembled. That there is hereby authorized to
be appropriated annually, out of any money in the
Treasury not otherwise appropriated, the sums spec-
ified in Section 2 of this Act, to be paid to the sev-
eral states for the purpose of cooperating with them
in promoting the welfare and hygiene of maternity
and infancy as hereinafter provided.
Sec. 2. For the purpose of carrying out the pro-
visions of this Act, there is authorized to be ap-
propriated, out of any money in the treasury not
otherwise appropriated, for the current fiscal year
$480,000, to be equally apportioned among the sev-
eral states, and for each subsequent year, for the
period of five years, $240,000, to be equally appor-
tioned among the several states in the manner here-
inafter provided: Provided, That there is hereby
authorized to be appropriated for the use of the
states, subject to the provisions of this Act, for the
fiscal year ending June 30, 1922, an additional sum
of $1,000,000, and annually thereafter, for the period
of five years an additional sum not to exceed $1,000,-
000: Provided further, That the additional appropri-
VoL. XII, No. 2]
Journal of Iowa State Medical Society
69
ations herein authorized shall be apportioned $5,000
to each state and the balance among the states in the
proportion which their population bears to the total
population of the states of the United States, accord-
ing to the last preceding United States census: And
provided further. That no payment out of the addi-
tional appropriation herein authorized shall be made
in any j-ear to any state until an equal sum has been
appropriated for that year by the legislature of such
state for the maintenance of the services and facili-
ties provided for in this Act.
So much of the amount apportioned to any state
for any fiscal year as remains unpaid to such state
at the close thereof shall be available for expendi-
tures in that state until the close of the succeeding
fiscal year.
Sec. 3. There is hereby created a board of mater-
nity and infant hygiene, which shall consist of the
chief of the children’s bureau, the surgeon general
of the United States Public Health Service, and the
United States commissioner of education, and which
is hereafter designated in this Act as the board. The
board shall elect its own chairman and perform the
duties provided for in this Act.
The Children’s Bureau of the Department of La-
bor shall be charged with the administration of this
Act, except as herein otherwise provided, and the
chief of the children’s bureau shall be the executive
officer. It shall be the duty of the children’s bureau
to make or cause to be made such studies, investiga-
tions, and reports as will promote the efficient ad-
ministration of this Act.
Sec. 4. In order to secure the benefits of the ap-
propriations authorized in Section 2 of this Act, any
state shall, through the legislative authority thereof,
accept the provisions of this Act and designate or
authorize the creation of a state agency with which
the children’s bureau shall have all necessary powers
to cooperate as herein provided in the administration
of the provisions of this Act: Provided, That in any
state having a child-welfare or child-hygiene division
in its state agency of health, the said state agency of
health shall administer the provisions of this Act
through such divisions. If the legislature of an}'
state has not made provision for accepting the pro-
visions of this Act the governor of such state may in
so far as he is authorized to do so by the laws of
such state accept the provisions of this Act and
designate or create a state agency to cooperate with
the children’s bureau until six months after the ad-
journment of the first regular session of the legis-
lature in such state following the passage of this
Act.
Sec. 5. So much, not to exceed 5 per centum of
the additional appropriations authorized for any
fiscal year under Section 2 of this Act, as the Chil-
dren’s Bureau may estimate to be necessary for ad-
ministering the provisions of this Act, as herein pro-
vided, shall be deducted for that purpose, to be avail-
able until expended.
Sec. 6. Out of the amounts authorized under Sec-
tion 5 of this Act the Children’s Bureau is authorized
to employ such assistants, clerks, and other persons
in the District of Columbia and elsewhere, to be
taken from the eligible lists of the civil service com-
mission, and to purchase such supplies, material,
equipment, office fixtures, and apparatus, and to in-
cur such travel and other expense as it may deem
necessary for carrying out the purposes of this Act.
Sec. 7. Within si.xty days after any appropriation
authorized by this Act has been made, the Children’s
Bureau shall make the apportionment herein pro-
vided for and shall certify to the secretary of the
treasury the amount estimated by the bureau to be
necessary for administering the provisions of this
Act, and shall certify to the secretary of the treas-
ury and to the treasurers of the various states the
amount which has been apportioned to each state for
the fiscal year for which such appropriation has been
made.
Sec. 8. Any state desiring to receive the benefits
of this Act shall, by its agency described in Section
4, submit to the Children’s Bureau detailed plans for
carrying out the provisions of this Act within such
state, which plans shall be subject to the approval
of the board: Provided, That the plans of the states
under this Act shall provide that no official, or agent,
or representative in carrying out the provisions of
this Act shall enter any home or take charge of any
child over the objection of the parents, or either of
them, or the person standing in loco parentis or hav-
ing custody of such child. If these plans shall be in
conformity with the provisions of this Act and rea-
sonably appropriate and adequate to carry out its
purposes they shall be approved by the board and
due notice of such approval shall be sent to the state
agency by the chief of the Children’s Bureau.
Sec. 9. No official, agent, or representative of the
Children’s Bureau shall by virtue of this Act have
any right to enter any home over the objection of
the owner thereof, or to take charge of any child
over the objection of the parents, or either of them,
or of the person standing in loco parentis or having
custody of such child. Nothing in this Act shall be
construed as limiting the power of a parent or guard-
ian or person standing in loco parentis to determine
what treatment or correction shall be provided for a
child or the agency or agencies to be employed for
such purpose.
Sec. 10. Within sixty days after any appropria-
tion authorized by this Act has been made, and as
often thereafter while such appropriation remains
unexpended as changed conditions may warrant, the
Children’s Bureau shall ascertain the amounts that
have been appropriated by the legislatures of the
several states accepting the provisions of this Act
and shall certify to the secretary of the treasury the
amount to which each state is entitled under the pro-
visions of this Act. Such certificate shall state (1)
that the state has, through its legislative authority,
accepted the provisions of this Act and designated
or authorized the creation of an agency to cooperate
with the Children’s Bureau, or that the state has
otherwise accepted this Act, as provided in Section 4
70
Journal of Iowa State Medical Society
[February, 1922
hereof; (2) the fact that the proper agency of the
state has submitted to the Children’s Bureau detailed
plans for carrying out the provisions of this Act, and
that such plans have been approved by the board;
(3) the amount, if any, that has been appropriated
by the legislature of the state for the maintenance of
the services and facilities of this Act, as provided in
Section 2 hereof; and (4) the amount to which the
state is entitled under the provisions of this Act.
Such certificate, when in conformity with the pro-
visions hereof, shall, until revoked as provided in
Section 12 hereof, be sufficient authority to the sec-
retary of the treasury to make payment to the state
in accordance therewith.
Sec. 11. Each state agencj^ cooperating with the
Children’s Bureau under this Act shall make such
reports concerning its operations and expenditures
as shall be prescribed or requested by the bureau.
The Children’s Bureau may, with the approval of the
board, and shall, upon request of a majority of the
board, withhold any further certificate provided for
in Section 10 hereof whenever it shall be determined
as to any state that the agency thereof has not
properly expended the money paid to it or the
moneys herein required to be appropriated by such
state for the purposes and in accordance with the
provisions of this Act. Such certificate may be with-
held until such time or upon such conditions as the
Children’s Bureau, with the approval of the board,
may determine; when so withheld the state agency
may appeal to the president of the United States
W'ho may either affirm or reverse the action of the
Bureau with such directions as he shall consider
proper: Provided, That before any such certificate
shall be withheld from any state, the chairman of the
board shall give notice in writing to the authority
designated to represent the state, stating specifically
wherein said state has failed to comply with the pro-
visions of this Act.
Sec. 12. No portion of any moneys apportioned
under this Act for the benefit of the states shall be
applied, directly or indirectly, to the purchase, erec-
tion, preservation, or repair of any building or build-
ings or equipment, or for the purchase or rental of
any buildings or lands, nor shall any such moneys
or moneys required to be appropriated by any stale
for the purposes and in accordance with the provi-
sions of this Act be used for the payment of any ma-
ternity or infancy pension, stipend, or gratuity.
Sec. 13. The Children’s Bureau shall perform the
duties assigned to it by this Act under the super-
vision of the secretary of labor, and he shall include
in his annual report to congress a full account of
the administration of this Act and expenditures of
the moneys herein authorized.
Sec. 14. This Act shall be construed as intending
to secure to the various states control of the ad-
ministration of this Act within their respective
states, subject only to the provisions and purposes
of this Act.
Approved, November 23, 1921.
67TH CONGRESS, 1ST SESSION— S. 2764
In the Senate of the United States. November
16 (calendar day, November 22), 1921.
Mr. Watson of Indiana introduced the following
bill; which was read twice and referred to the com-
mittee on finance.
A Bill to Recognize and to Promote the Efficiency
of the United States Public Health Service
Be it enacted by the Senate and House of Repre-
sentatives of the United States of America in Con-
gress assembled. That not to exceed five hundred
and fifty officers of the Reserve Corps of the Public
Health Service, including fifty dental surgeons and
fifty scientists other than medical officers, may be
transferred to and commissioned in the regular corps
of commissioned officers of the Public Health Ser-
vice by the president, by and with the advice and
consent of the Senate, in the grades of assistant sur-
geon, passed assistant surgeon, surgeon, senior sur-
geon, and assistant surgeon general (hereafter as-
sistant surgeon generals shall be known and desig-
nated as medical directors): Provided, That no of-
ficer shall be commissioned or promoted under this
Act until after passing before a board of regular
commissioned officers of the Public Health Service
an examination in accordance with regulations pre-
pared by the surgeon general and approved by the
secretary of the treasury and the president. Here-
after officers of the regular commissioned corps of
the Public Health Service shall be promoted to the
grade of passed assistant surgeon after three years’
commissioned service, to the grade of surgeon after
twelve years’ commisioned service, to the grade of
senior surgeon after twenty years’ commissioned ser-
vice, and to the grade of medical director after twen-
ty-six years’ commissioned service. For the purpose
of future promotion any person appointed in a grade
above that of assistant surgeon shall be considered
as having had on the date of appointment service
equal to that of the junior officer of the grade to
which appointed in the regular corps: Provided,
That any person transferred to and commissioned
in the regular corps under the provisions of this Act
at an age greater than forty-five years, if placed on
“waiting orders” for disability incurred in line of
duty, shall receive pay at the rate of 4 per centum
of active pay for each complete year of service in
the Army, Navy or Public Health Service, the total
to be not more than 75 per centum: Provided
further. That no officer shall be transferred to and
commissioned in the regular commissioned corps un-
der the provisions of this section who has not had a
total of three years’ satisfactory service in the Army,
Navy or Public Health Service, a part of which ser-
vice must have been between April 6, 1917, and No-
vember 11, 1918: Provided further. That all officers
transferred and commissioned under this Act shall
receive the same pay, allowances, and increases and
shall be subject to the same rules and regulations as
now are, herein are, or hereafter may be prescribed
VoL. XII, No. 2]
Journal of Iowa State Medical Society
71
by law or regulations for commissioned personnel of
the same rank or grade in the regular corps of the
United States Public Health Service.
A vacancy in the grade of surgeon general shall be
filled by appointment by the president, by and with
the advice and consent of the senate, from among the
commissioned officers who have a total of not less
than twelve j'ears’ commissioned service in the Pub-
lic Health Service. The term of office of the surgeon
general shall be for the period of four years, at the
expiration of which term of office he shall, unless re-
appointed, be appointed a medical director. The sur-
geon general shall receive the same pay and allow-
ances as the surgeon general of the United States
Army.
Sec. 2. That persons who have had no service in
the Army, Navy, or Public Health Service during the
period between April 6, 1917, and November 11, 1918,
may receive an original commission in the grade of
assistant surgeon only; no such person shall be com-
missioned until after passing a satisfactory physical
and professional examination before a board of reg-
ular commissioned officers of the Public Health Ser-
vice. Said examination shall be conducted according
to the rules prepared by the surgeon general and ap-
proved by the secretary of the treasury and the pres-
ident. No such officer shall be promoted until after
passing an examination in accordance with regula-
tions prepared by the surgeon general and approved
by the secretary of the treasury and the president.
The provisions of this section shall not apply to the
professors of the hygienic laboratory (seven in num-
ber) who may be appointed by the president, by and
with the advice and consent of the Senate, in the
regular commissioned corps in any grade below that
of surgeon general according to the needs of the
service, but no person shall be commissioned as such
until after passing a satisfactory examination in the
several branches of his profession before a board of
commissioned officers; said examination shall be
conducted in accordance with rules prepared by the
surgeon general and approved by the secretary of
the treasury and the president.
Sec. 3. That there shall be in the United States
Public Health Service a corps of nurses, dietitians,
and reconstruction aids. This corps shall consist of
(1) one superintendent of nurses, one superintendent
of dietitians, one superintendent of reconstructions
aids; (2) assistant superintendents of nurses, assist-
ant superintendents of dietitians, assistant superin-
tendents of reconstruction aids; (3) chief nurses,
chief dietitians, chief reconstruction aids; (4) assist-
ant chief nurses, assistant chief dietitians, assistant
chief reconstruction aids; (5) head nurses, head dieti-
tians, head reconstruction aids; (6) nurses, dietitians,
reconstruction aids; (7) student nurses, student dieti-
tians, student reconstruction aids, as from time to
time may be needed and prescribed by the secretary
of the treasury. Original appointments shall be
made by the secretary of the treasury upon recom-
mendation of the surgeon general, after qualifying
under rules prescribed by the civil service commis-
sion. The compensation of the corps shall be at the
following annual rates: Superintendent of nurses,
$3,500; superintendent of dietitians, $3,500; superin-
tendent of reconstruction aids, $3,500; assistant su-
perintendents of nurses, assistant superintendents of
dietitians, assistant superintendent of reconstruction
aids, $2,740; chief nurses, chief dietitians, chief re-
construction aids, $2,360; assistant chief nurses, as-
sistant chief dietitians, assistant chief reconstruction
aids, $1,980; head nurses, head dietitians, head recon-
struction aids, $1,800; nurses, dietitians, reconstruc-
tion aids, $1,740. No member of this corps shall re-
ceive the congressional bonus now allowed by law.
Student nurses, dietitians, and reconstruction aids
shall receive such pay as may be prescribed by the
secretary of the treasury. When a nurse or recon-
struction aid i.s serving on duty in a hospital for con-
tagious diseases, or for neuropsychiatric or tuber-
culous patients as a nurse or aid to such patients, she
shall receive $75 per annum increase in her pay. If
for the convenience of the service a member of this
corps is furnished quarters or subsistence she shall
pay the cost thereof as determined by the secretary
of the treasury, and the same shall be deducted from
her pay.
Sec. 4. That all laws and parts of laws in so far
as they are inconsistent with this Act are hereby
repealed.
SOCIETY PROCEEDINGS
Allamakee County Medical Society
The Allamakee Medical Society met December 14
at the court house and the following officers were
elected: President, Dr. A. A. Schmidt of Postville;
vice-president. Dr. J. H. Thornton of Lansing; sec-
retary-treasurer, Dr. John W. Thornton of Lansing:
delegate to State Medical Society, Dr. A. A. Schmidt
of Postville. The county nurse also was in attend-
ance at the meeting.
Bremer County Medical Society
The annual meeting of the Bremer County Medical
Society was held at St. Joseph’s Hospital, Waverly,
December 16, 1921. Officers elected for the year
were: President, M. N. Gernsey, Waverly; vice-
president, F. R. Sparks, Waverly; secretary-treas-
urer, F. J. Epeneter, Denver; delegates, F. A. Osin-
cup and L. C. Kern.
Following a prevailing motion at this meeting, the
physicians of Waverly will discontinue carrying
cards in the local press. A paper on Pyogenic In-
fection of the Kidney was presented by Dr. L. A.
West.
Arrangements are under way for the holding of a
children’s clinic, also a tuberculosis clinic by the
society. F. J. Epeneter, Sec’y.
Butler County Medical Society
The Butler County Medical Association held a
meeting in Dr. B. Ensley’s office the afternoon of
72
Journal of Iowa State Medical Society
[February, 1922
December 14. Dr. J. Nevins of Greene presided.
Those in attendance from out of town werei Dr.
M. B. Call, Greene; Dr. Groom, Greene; Drs. Day
and Smith, Clarksville; Dr. C. F. Roder Aredale, and
Dr. Nash, Bristow; Dr. Hobson, Parkersburg. Dr.
Reeve of Allison, president of the association, was
not present.
Calhoun County Medical Society
The Calhoun County Medical Society held its reg-
ular annual meeting last Thursday afternoon and
evening, December IS, in the American Legion Hall,
Pomeroy, Iowa, the society being the guests of Drs.
C. I. Taylor and W. W. Weber of Pomeroj'^. The
program follows — Papers: Preoperative Manage-
ment of Prostatitis, Dr. Albert A. Schultze of FL
Dodge. A Plea for the Child’s Tonsil, Dr. F. E.
Kauffman, Lake City.
The following officers were elected for the ensu-
ing year: President, F. E. Kauffman, Lake City;
vice-president, T. B. Herrick, Manson; secretary and
treasurer, Lena A. Beach, Rockwell City.
The following physicians were present: Albert A.
Schultze, Ft. Dodge; C. I. Taylor and W. W. Weber,
Pomeroy; T. B. Herrick, Robt. C. Henricks, Pretty-
man, and Myrtle Griffin, Manson; Lena A. Beach, J.
M. Cooper, L. E. Eslick, and P. W. Van Metre,
Rockwell City; A. B. Carstensen, Jolley; Thos. H.
Van Camp, Somers; D. J. Townseiid, J. W. Craig
and A. R. Isenberg, Lohrville; M. J. McVay, W. E.
McCrary, and F. E. Kauffman, Lake City.
Clinton County Medical Association
At the annual meeting of the Clinton County Med-
ical Association held with a dinner December 15 at
the Lafayette Hotel, officers were elected as follows:
President, Dr. H. C. ^Martin; vice-president. Dr. R.
F. Luce, Low ^loor; secretarj’-treasurer, Dr. Ikl. S.
Jordan; delegates to state convention. Dr. J. C. Lan-
gan and Dr. H. R. Sugg.
Cerro Gordo County Medical Society
The monthly meeting of the Cerro Gordo Count'
Medical Society was held in the Park Hospital at
Mason City, on Tuesdaj' evening January 24, at 8:30
p. m. Twenty-two members and one visitor. Dr.
Saunders from Northwood, were present.
Dr. Nicholas Stam from the Park Hospital Clinic
was elected to membership in the society.
Dr. L. R. Woodward presented a case of Heart
Block and discussed the subject of Cardiac Arrhy-
thmia. Further discussion was presented by Dr. J.
H. Fraser.
Dr. V. A. Farrell presented a case of ^Mediastinal
Tumor. Discussion of Mediastinal Tumors followed
by Dr. G. AI. Crabb, who also showed microscopic
sections of one of the nodules removed from beneath
the skin of this patient, apparently a metastasis from
the Mediastinal Tumor.
Light refreshments were served by the members
of the Park Hospital staff and a short social session
followed. Wilbur L. Diven, Sec’y.
Decatur County Medical Society
After a special luncheon at Brewers cafe, the De-
catur County Aledical Societj' met in the office of
Dr. F. A. Bowman on the evening of December 28.
The following program was presented: Carbuncles,
H. R. Layton of Leon; Report of the State Medical
Society, T. W. King of Lamoni.
After these papers had been discussed, there was
an informal discussion of the Treatment of Burns.
The following officers were elected for the ensu-
ing year: AI. Phelps, Van Wert, president; T. W.
King, Lamoni, vice-president; C. H. Alitchell, Leon,
secretary-treasurer; F. A. Bowman, Leon, delegate:
E. Alitchell, Grand River, alternate.
C. H. Alitchell, Sec’y-Treas.
Des Moines County Medical Society
Afore than sixty physicians from Iowa and Il-
linois attended the annual banquet of the Des Aloines
Aledical Society, in Hotel Burlington, December 13.
Talks were given by some of the most eminent doc-
tors in the country, specialists on the subjects they
lectured on. Stereopticon pictures were used to il-
lustrate the technical subjects treated.
A business meeting of the Des Aloines Gountj"
Medical Society preceded the dinner. This was
held at 4 o’clock in the afternoon. Dr. Jas. S.
Cooper was elected president; Dr. G. J. Pearson,
vice-president; Dr. George H. Steinle, secretary and
treasurer. After this meeting the lectures by visit-
ing physicians were given. Dr. George H. Steinle,
retiring president of the societjq welcomed the
visitors and the medical program began by a talk
given by Dr. Robert Bruce Preble of the Northwest-
ern University at Evanston, Illinois. He spoke on
Syphilis of the Aorta. He was followed by Dr. H. H.
Kramolosky of St. Louis, who talked on Pjmria, and
used slides.
Dr. D. B. Phemister of Chicago used pictures in
telling of Some Unusual Forms of Osteomyelitis, or
Infection of the Bone.
The closing talk was given by Dr. Eugene R. Van
Aleter of St. Louis.
The guests at the banquet, which was served at
6:30 o’clock, were the following doctors: Robert B.
Preble, Chicago; Eugene R. Van Aleter, St. Louis;
D. B. Phemister, Chicago; H. H. Kiamolowsky, St.
Louis; Wm. S. Reilly, Oquawka, Illinois; W. H.
Scott, Dallas City, Illinois; D. L. Newton, Ft. Aladi-
son; W. B. Broek, Oakville; E. E. Kirkendall, W.
Burlington; A. E. Lawser, Stronghurst, Illinois; C.
F. Wahrer, Ft. Aladison; R. C. Ditto, Oakville;
Thomas Bess, Ft. Aladison; A. D. Phillips, Ft. Madi-
son; Clayton J. Hyslop, Galesburg, Illinois; John
Bohan, Galesburg, Illinois; T. T. Coe, Keithsburg,
Illinois; R. S. Reimers, Ft. Aladison; E. A. Stewart,
Alt. Pleasant; W. H. Johnston, Aluscatine; T. F.
Beveridge, Aluscatine; Chas. B. Taylor, Ottumwa:
VoL. XII, No. 2]
Journal of Iowa State Medical Society
73
Charles Ricksher, Fairfield; O. A. Geseka, Mt.
Pleasant; F. C. Mehler, New London; W. R. Smyth,
Morning Sun; T. R. Meliler, New London; C. L.
Emerson, Stronghurst, Illinois; W. J. Emerson, Lo-
max, Illinois; H. L. Marshall, Stronghurst, Illinois;
N. B. Hoornbeck, Youngstown, Illinois; H. V. Pres-
cott, Dallas City, Illinois; H. L. Kampen, Monmouth,
Illinois; F. W. Noble, Ft. Madison; O. W. McGrew,
Columbus Junction; S. J. Lewis, Columbus Junction;
Chas. N. Stephens, Gladstone, Illinois; J. S. Gaumer,
Fairfield; Ralph Graham, Monmouth, Illinois; Chas.
P. Blair, Monmouth, Illinois; B. O. Clanahan, Gales-
burg, Illinois; J. R. Ebersole, Monmouth, Illinois;
H. M. Camp, Monmouth, Illinois; H. H. Moore,
Ottumwa; C. E. Cook, New London; L. D. James,
Fairfield; W. L. Stewart, Mediapolis; G. W. Cleuke,
Rossville, Illinois; G. M. VanAusdell, New London;
J. C. Redenglon, Galesburg, Illinois; Louis N. Gate,
Galesburg, Illinois; James J. Allen, Kirkwood; M. J.
Babcock, Biggsville, Illinois; H. S. Zimmerman,
Cameron; W. S. Lessenger, Mt. Pleasant; J. G. Har-
ter, Stronghurst, Illinois; J. M. McClanahan, Kirk-
wood, Illinois; E. W. Harrison, Winfield; D. Y.
Graham, Morning Sun; J. T. McConnoughy, Win-
field; H. G. Ebersole, Monmouth, Illinois; J. W.
Lavinse, Ft. Madison; C. W. Gardner, Mt. Pleasant;
E. J. Lessenger, New London; E. G. Wollenweber,
Keokuk.
Burlington guests — C. E. Kaufman, N. McKit-
terick, G. H. Steinle, Jas. S. Cooper, E. I. Wood-
bury, H. T. Kriechbaum, B. L. Ditto, J. N. Patterson,
E. F. LaForce, D. F. Huston, F. M. Tombaugh, Geo.
J. Pearson, A. H. Vorwerk, J. J. Kelly, Fred E. Koch,
G. A. Chilgren, A. B. George, G. B. Crow, P. H.
Schaefer, Chas. P. Frantz, W. P. Kriechbaum, R. F.
Karney, A. J. Thornber, A. C. Moerke, J. W. Green-
man, B. F. Campbell, C. W. Bone and Louis Lau.
Dubuque County Medical Society
At a largely attended meeting of the Dubuque
County Medical Society held December 14 at the
Chamber of Commerce the annual election of offi-
cers for the ensuing year and other routine business
took place.
A feature of the program following routine busi-
ness was a case report on lung abscess by Drs.
Painter, Johnston and McNamara.
Newly elected officers of the society are: Dr.
Mary Killeen, president; Dr. W. Cary, first vice-
president; Dr. O. E. Haisch, second vice-president;
Dr. H. E. Thompson, secretary; Dr. G. C. Fritschel,
treasurer; Dr. M. J. Moes, delegate; Dr. H. M.
Pahlas, alternate delegate; Dr. Lewis Linehan, Dr.
C. E. Lynn and Dr. C. C. Lytle, board of censors;
Dr. H. A. Stribley, librarian.
Fremont County Medical Society
The annual meeting of the Fremont County Medi-
cal Society was held at Hamburg, January 6, at the
Hamburg Hospital. A profitable discussion on the
subject of Diabetes Mellitus constituted the scien-
tific part of the meeting. Officers elected for the
year are: President, Wm. Kerr, Randolph; vice-
president, R. C. Danley; secretary-treasurer, A. E.
Wanamaker; delegates, E. E. Richards and B. B.
Miller, all of Hamburg.
At the next meeting of the society to be held in
May at Randolph, the membership will be the guests
of President Dr. Kerr, celebrating the twentieth an-
niversary of Dr. Kerr’s practice at Randolph.
A. E. W.
Hancock-Winnebago County Medical Society
The annual meeting of the Hancock-Winnebago
County Medical Society, was held at Corwith, Janu-
ary 9. At this meeting a most excellent scientific
program was carried out, among the papers pre-
sented was one by Dr. N. C. Stamm of the Park
Hospital Clinic, Mason City, on Kidney Lesions.
He gave a very interesting and instructive discussion
on the different lesions met with in urological work,
and reported cases and showed specimens and
pyleographs of both renal tuberculosis, and hyper-
nephroma. The general discussion by the physicians
present brought out much of interest.
Dr. C. G. Field of Ft. Dodge gave a lengthy and
interesting discussion of the Treatment of Heart
Disease and his dissertation was followed by some
very spicy discussions, in which the features of his
talk were thoroughly brought out, the points dealing
with Egglestons Dosage, and auricular fibrillation
being presented by the different members present,
from their respective viewpoints.
Following the scientific program the physicians
present were entertained by R. S. Fillmore, M.D.,
and C. F. Stull, D.D.S., of Corwith, at an elaborate
roast pig banquet; and as entertainers, Drs. Fillmore
and Stull were voted 100 per cent efficient.
In the evening the Wertheim Obstetrical Film was
exhibited at the local movie theatre, and for nearly'
two hours the audience saw the different phases of
obstetrical work, from normal delivers to Caesarian
section, from a breech presentation to perforation of
the skull. Thus giving a clinic, for such it was, by a
county society, is something of an inovation, but one
that was thoroughly enjoyed by all present. It was
voted the most instructive feature, and the secretary
was instructed to secure other pictures for future
meetings. Officers elected for the ensuing year;
President, Dr. R. S. Fillmore, Corwith; vice-presi-
dent, B. F. Denney, Britt; secretary-treasurer, H. F.
Thompson, Forest City; delegates, A. L. Judd, Kan-
awaha, and R. S. Fillmore, Corwith; censors, G. F.
Dolmage, A. L. Judd and H. R. Irish.
H. F. Thompson, Sec’y.
Henry County Medical Society
The quarterly meeting of the Henry County Med-
ical Society was held in Mt. Pleasant recently and
at the invitation of the superintendent of the new
hospital the entire day was spent at the institution.
The morning session was held in the nurses living
74
Journal of Iowa State Medical Society
[February, 1922
room on the first floor and was devoted to business.
The following officers were elected for the coming
year: President, Dr. C. W. Gardner; vice-president.
Dr. W. A. Sternberg; secretary-treasurer. Dr. E. A.
Stewart.
Three officers of the medical association were
also elected as the advisory committee of the county
physicians to confer with the trustees of the hospital
and the superintendent concerning the management
of the institution and other matters of interest to
the hospital and the profession.
At the noon hour the members of the medical as-
sociation, the members of the Henry County Dental
Association were invited to lunch as guests of the
hospital. The lunch was a sample of the standard
meal furnished by the hospital demonstrating just
what patients would be fed. The tables were set up
in the corridor of the first floor and thirty-five were
seated. The three registered nurses and Misses
Hobbs and McFerran served the meal.
At two o’clock the society met for the afternoon
session in the sun parlor on the second floor and
listened to a most profitable program with papers
by Dr. Tombaugh of Burlington and Dr. Boyce of
Washington and an inspiring address by Dr. Brock-
man of Ottumwa. On motion the paper of Dr.
Boyce will be published in the News.
Ida County Medical Association
The annual meeting of the Ida County Medical
Association was held in Holstein on Friday evening,
December 9, and after an enjoyable dinner the meet-
ing was called to order in the directors’ room of the
First State Bank. Drs. Parker of Ida Grove and
Crane of Holstein read very interesting papers fol-
lowed by a general discussion and round table talk.
The officers for the coming year were elected as
follows:
President, Dr. G. C. Aloorehead of Ida Grove;
vice-president, Dr. E. C. Heilman of Ida Grove; sec-
retary-treasurer, Dr. C. S. Stoakes of Battle Creek;
delegate to state convention. Dr. A. M. Bilby of
Galva.
Jasper County Medical Society
The Jasper County Medical Association met in
Prairie City Tuesday, December 13. At that time
they elected officers for the coming year. Dr. W. E.
Anspach of Colfax was again elected to fill the office
of secretary-treasurer. Dr. Harnagel of Des Moines
and Dr. Peter Haney of Prairie City gave the princi-
ple addresses which were very instructive and were
followed by discussions. Dr. Martin of Des Moines
and several other visitors were present. Those pres-
ent report the meeting a fine success.
Johnson County Medical Society
New officers of the Johnson County Medical So-
ciety were elected at a meeting of the society Wed-
nesday evening, December 21. Dr. J. H. Wolfe was
elected president for the coming year. Dr. George
C. Allbright, vice-president, and Dr. L. G. Lowrey
was elected secretary and treasurer.
Dr. N. G. Alcock was elected a member of the
board of censors, and Dr. H. J. Prentiss was elected
delegate to the state convention at Des Moines.
Lee County Medical Society
The thirty-seventh annual meeting of the Lee
County Medical Society was held at Fort Madison
December 29. Dr. O. T. Clark of Keokuk, president
of the society, called the meeting to order at 2:30.
Minutes of the last meeting which had been held in
Keokuk were read and approved. A report was then
made by Dr. Newlon, chairman of the committee ap-
pointed to consider whether it were advisable to
have more numerous meetings. The committee rec-
ommended not more meetings at present, but more
interest shown in the meetings held.
Officers elected for the year follows: Dr. I. W.
Travers of Fort Madison, president; R. M. Lapsley
of Keokuk, vice-president; Dr. William Rankin of
Keokuk, secretary-treasurer; Dr. F. M. Fuller,
delegate to state convention; Dr. Thomas Bess, Fort
Madison, alternate.
Dr. Hogle remains censor to 1924, Dr. Newlon to
1923 and Dr. Noble was elected with term expiring
•1925.
Dr. H. M. Richter of Chicago, a member of the
faculty of the Northwestern College of Medicine was
the speaker of the afternoon and his topic was
Gastric Lesions. His talk was listened to with much
interest. Discussion by Dr. !McGee of Burlington,
Drs. Fuller, Ryan and Crowe. Dr. Wahrer moved
that the courtesy of the floor be extended to Dr.
Richter, the motion was carried by a rising vote.
Dr. Ryan of Des Moines, discussed the topic of
Medical Treatment of Goitre and Gas Oxygen Anes-
thesia discussed by Dr. W. C. Kasten of Fort Madi-
son.
The question of increasing county dues to $5 and
making the total for state and county $10 instead of
$6 will be discussed at the semi-annual meeting in
Keokuk May 4, 1922.
Drs. Fuller, Armentrout and Clark were appointed
members of the committee to arrange for this meet-
ing.
Doctors attending from Keokuk were Fuller, Ran-
kin, Lapsley, Clark and Charles Wilkins of Dakota.
Mahaska County Medical Society
The Mahaska County Medical Society held its an-
nual election of officers at a banquet, including the
ladies at the Chamber of Commerce rooms, Oska-
loosa, 6:30 p. m., December 21, 1921.
Dr. C. E. Ruth of Des Moines was the guest of
honor and gave the society a very interesting stere-
opticon lecture on Fractures of the Long Bones,
A rising vote of thanks was extended to the Doctor,
and an invitation to come again.
The superintendents of the nurses training schools'
secretary of the Social Service League, and Red
VoL. XII, No. 2 1
Journal of Iowa State Medical Society
75
Cross Nurses of the city were also guests of the
society. Matters of importance to the betterment
of the community were inaugurated. The commun-
ity young ladies orchestra furnished music during
the meal.
The following are the officers for the ensuing
year. Dr. Fred J. Jarvis, president; Dr. John A.
Ruan, vice-president; Dr. Francis A. Gillett, secre-
tary and treasurer.
F. A. Gillett, Sec’y-
Marion County Medical Society
The Marion County Medical Society met in reg-
ular forty-ninth annual session at Knoxville, the
afternoon of December 15. The following program
was presented; A Plea for Closer Cooperation Be-
tween the Physician and Dentist, Especially as Re-
gards the Problem of Pre-Natal Care, Dr. W. R.
Garretson, Knoxville. Some Facts and Problems in
Infant Feeding, Dr. Fred Moore, Des Moines. A
Paranoiac and His Book, Dr. J. R. Wright, Knox-
ville.
The following officers were elected for 1922: Pres-
ident, Dr. F. M. Roberts, Knoxville; vice-president.
Dr. Roy Moon, Attica; secretary-treasurer, Dr. C. S.
Cornell, Knoxville. Delegate, Dr. E. G. McClure,
Bussey; alternate. Dr. J. R. Wright, Knoxville; cen-
sor; Dr. H. E. White, Knoxville.
The attendance was excellent, thirty members of
the medical and dental professions from Marion
and neighboring counties profiting by one of the
best scientific programs the society has ever had.
The next meeting will be held in Knoxville in
April.
C. S. Cornell, Sec’y-Treas.
Marshall County Medical Society
Dr. R. E. Keyser was elected president and Dr. F.
L. Wahrer secretary and treasurer at the annual
meeting of the Marshall County Medical Society. Dr.
Otis Wolfe was elected vice-president and Dr. M. U.
Chesire, delegate to the State Society Convention
and Dr. Theodore Engle of State Center, alternate.
The censors elected were Dr. R. R. Hansen, Mar-
shalltown and Dr. A. D. Wood, State Center, and
Dr. H. E. Noble, Clemons.
Dr. Woods read a paper on Cervical Rib.
Muscatine County Medical Society
The annual meeting of the Muscatine County Med-
ical Society was held December 21, 1921, parlor A,
Muscatine Hotel.
Dr. Paul A. White of Davenport, Iowa, presented
a paper and slides on Uses of Radium, which was
very interesting, instructive and enjoyed by all
present.
Officers elected for 1922 were: President, Dr. W.
H. Johnston; vice-president. Dr. W. W. Daut; secre-
tary-treasurer, Dr. W. W. Potter; delegate. Dr. E. K.
Tyler. After the meeting a luncheon was enjoyed at
the Geo. Washington cafe.
Scott County Medical Society
A regular meeting of the Scott County Medical So-
ciety was held Tuesday evening, December 6, 1921,
in the Chamber of Commerce, Davenport, Iowa.
Dinner served at 6:30 P. M. Meeting called to order
at 8:00 P. M. sharp. Election of officers by ballot,
for the year 1922.
Program— General discussion bn ways and means
to create more interest among the members of the
society for the benefit of the society.
SECRETARY’S YEARLY REPORT FOR THE
YEAR 1921
Ten regular meetings held during the year.
One special meeting called.
Free Ambulance Service— Through the efforts of
President Dr. E. O. Ficke and Mayor C. L. Bare-
wald, physicians will receive free ambulance services
for their patients in the city limits of Davenport. It
is hoped that the members of the society will insist
on this free service of the ambulance to their patients
in the future.
Parking Privileges — Through the efforts of Presi-
dent Dr. E. O. Eicke and Dr. Wm. L. Allen, a peti-
tion was circulated and presented to Mayor C. L.
Barewald to extend parking privileges to physicians
during the year. Mayor Barewald granted the park-
ing privileges and requested all physicians wishing
to take advantage of the parking privileges, to place
a caduceas on their cars and secure a card from the
mayor. This would permit physicians to park their
cars in the down town parking zones for two hours
in the mornings and three hours in the afternoons.
It is hoped that the society will be granted the same
privileges in the future.
Closing Wednesday Afternoons— From July first
to September first, during the year 1921, was voted
on by the society. Cards were printed and placed in
each physician’s office to advise their patients of the
action taken by the society.
Total members in the society beginning Jan, 1921 76
New members accepted into the society during
the year 7
Applicants rejected during the year 2
Members leaving the city during the year 1
Deceased members during the year 1
Honorary members 3
Total members December 31, 1921 84
Robert E. Jameson, Sec’y.
Taylor County Medical Society
The annual meeting of the Taylor County Medical
Society was held Tuesday afternoon at Dr. Sollis
office. After transacting the usual business the
election of officers took place as follows: Dr. Miller
of Blockton, president; Dr. King of Blockton, sec-
retary; Dr. Sollis of Bedford, delegate to the state
convention.
Dr. Harry S. Conrad, a surgeon of St. Joseph,
spoke on Surgery of the Breast. His talk was both
instructive and interesting.
Dr. H. C. Paul of St. Joseph spoke on Genitourin-
76
JOURXAL OF IoWa StATE MeDICAL SOCIETY
[February, 1922
ary. This subject every doctor p.Asent tu u- t deep
interest in and no doubt will profit by it in their
practice.
Next on the program was Dr. F. E. Sampson of
Creston, a man who is well known over the entire
state. His subject was the building of a community
hospital in Bedford.
Present at this meeting; Dr. J. W. Beauchamp,
Dr. Maloy, Dr. Sollis of Bedford; Dr. D. W. Reed of
Clearfield, Dr. A. E. King of Blockton and Dr. Miller
of Blockton.
Van Buren County Medical Society
The Van Buren County Medical Society held its
regular meeting at the rest room in Keosauqua,
Thursday, December 8, and it was regarded as one of
the most interesting and instructive meetings of the
society. The main feature of the session was an
address by Dr. W. B. LaForce of Ottumwa, his
theme being medical and other conditions in China.
The speaker had spent four years in China, hence
was well equipped for ably and authoritatively pre-
senting his interesting subject. Quite a crowd of
Keosauqua citizens enjoyed the talk.
It was agreed that a meeting should be held later
in honor of Dr. G. R. Neff of Farmington and Dr.
T. G. kIcClure of Douds, who have each completed
a service of fifty years of medical practice, nearly all
of which has been in this county.
The following officers were elected; Presideni,
Dr. McClure of Douds; vice-president, Dr. Neff of
Farmington; secretary-treasurer. Dr. Russell of
Keosauqua; delegate to state meeting, Dr. Cresap of
Bonaparte; alternate. Dr. Mathews of Mt. Sterling.
Webster County Medical Society
Dr. A. E. Acher was elected president of the Web-
ster County Medical Association at the annual meet-
ing in the Commercial Club rooms, Tuesday night,
December 6. Other officers elected for the coming
year were Dr. George Gibson, vice-president, and Dr.
T. J. Dorsey, secretary and treasurer.
Dr. W. F. Carver and Dr. A. H. McCreight were
elected delegates to the State Medical Association
which meets in Des Moines in the spring.
Following the election of officers Dr. L. M. Jilar-
tin gave a paper on the subject of Accessory Sinus
Infections.
I Woodbury County Medical Society
At the annual meeting of the Woodbury County
Medical Society held December 28 at Sioux City, the
following officers were elected: President, Dr. W.
J. S. Cremin; vice-president, Roy F. Bellaire, secre-
tary-treasurer, Victor Brown. William Jepson, of
Sioux City, addressed the members on the subject of
The Moral Obligations We Owe the Members of
Our Profession. A general discussion of the subject
concluded the program.
Boone Medical Society
The Boone Medical Society held its annual meet-
ing Wednesday evening, December 28 in Dr. Bas-
sett’s office at Boone and after the regular routine
had. been disposed of the following were elected for
the ensuing year: L. A. Bassett, president; J. O.
Ganoe, Ogden, vice-president; C. A. Nolan, secre-
tary; A. B. Deering, delegate to state convention
with L. A. Bassett, alternate. M. A. Healy, censor.
Upper Des Moines Medical Society
Fifty physicians and surgeons of Clay, Dickinson,
Palo Alto and Emmet counties gathered in Spencer
Thursday, December 1 at a meeting of the Upper
Des Moines Medical Society.
The visiting doctors and representatives of the
local civic organizations were guests of the Clay
County Medical Society at a banquet at the Hotel
Tangney Thursday evening, at which talks were
made on medical and public health topics. A score
of ladies were among the guests.
The Upper Des Moines Medical Society elected
the following officers: President, Dr. E. W. Sproule,
Peterson; vice-president. Dr. C. C. Collester, Spen-
cer; secretary, Dr. H. L. Brereton, Emmetsburg.
Those who attended the dinner included the fol-
lowing doctors:
Dickinson — M. P. Bachman, Lake Park; W. E.
Bullock, Lake Park; C. M. Coldren, Milford; C. O.
Epley, Spirit Lake; Q. C. Fuller, Milford; P. G.
Grimm, Spirit Lake; A. H. Schooley, Terril; C. S.
Shultz, Spirit, Lake; A. F. Smith, Milford; F. J.
Smith, Milford.
Clay — J. H. Bruce, Dickens; C. C. Collester, Spen-
cer; DeGarzon, Everly; H. O. Green, Spencer; T. H.
Johnston, Spencer; D. S. Jones, Royal; E. R. Leon-
ard, Everly; E. E. Munger, Spencer; E. A. Rust,
Webb; J. M. Sokol, Spencer; E. W. Sproule, Peter-
son; Porter-Wertz, Spencer; J. B. Wertz, Spencer;
C. C. Winter, Greenville,.
Emmet — E. W. Bachman, Estherville; J. T. Beck,
Gruver; C. E. Birney, Estherville; W. E. Bradley,
Estherville; R. C. Coleman, Estherville; V. H. Gard-
ner, Estherville; J. B. Knipe, Armstrong; H. D.
Mereness, Dolliver; M. T. Morton, Estherville; A.
A. Rhonalt, Ringsted; Alice C. Stinson, Estherville;
G. H. West, Armstrong; M. E. Wilson, Estherville.
Palo Alto — G. Baldwin, Ruthven; E. D. Beatty,
Mallard; H. L. Brereton, Emmetsburg; F. X. Cretz-
meyer, Emmetsburg; H. F. Givens, West Bend; J.
Hennessy, Emmetsburg; P. J. Hession, Graettinger;
H. M. Huston, Ruthven; G. H. Keeney, Mallard;
C. W. Morrison, Ayrshire; T. T. Naae, Graettinger;
Paul Nelson, Ayrshire; H. A. Powers, Emmetsburg;
H. R. Powers, Emmetsburg; G. J. Schuell, West
Bend; J. C. Walker, Emmetsburg; J. W. Woodbridge,
Ayrshire.
I wish to make mention of the annual birthday
celebration of Dr. W. A. Rohlf January 5, 1922 at
Waverly. An interesting clinic was held and lec-
VoL. XII, No. 2]
Journal of Iowa State Medical Society
77
tures and discussions at the hospital. Among the
doctors present were Dr. Granville Ryan of Des
Moines, Dr. Bookbinder of Chicago, doctors from
Iowa City, Charles City, Waterloo, Algona, and all
the surrounding towns. About sixty doctors at-
tended and more would have attended but for the
bad roads.
Dr. Rohlf proved as usual an ideal host. It is
interesting to note that no similar affair of its kind
exists in the State of Iowa, that is on so large a
scale. At the close of the banquet the lights were
extinguished and two ladies appeared with two large
birthday cakes, lighted with fifty-five small candles
on each. This proved almost too much for the Doc-
tor but he composed himself and gave us a touching
address. Those who have attended during the past
twelve years say this was the best ever.
•Fraternally yours,
“One Who Attended.”
LECTURES IN OPHTHALMOLOGY
The ophthalmic section of the St. Louis Medical
Society announces a course of lectures in ophthal-
mology, to be given in St. Louis by Professor Ernst
Fuchs of Vienna during the month of February, 1922.
Further information regarding this course may be
obtained by writing to the Fuchs Lecture Commit-
tee, St. Louis Medical Society, 3525 Pine street, St.
Louis, Missouri.
HOSPITAL NOTES
The Reverend Mother Superior Mary Philomene,
head of Mercy Hospital, Des Moines, died suddenly
at 3:45 A. M. Wednesday, December 28, from a
hemorrhage of the lungs, and passed on to her re-
ward, after more than forty years of faithful service.
The sister of mercy leaves as a monument to her
memory one of the largest hospitals in the state —
Mercy Hospital.
The hospital was her dream, which bit by bit was
realized until finally she had completed her work
and there remained the present hospital of 250-bed
capacity.
When a young girl in Davenport, Iowa, where she
was born sixty years ago. Miss Sara Keating made
the decision that she would devote her life to helping
others.
She entered a convent and forty years ago took
the veil. Thirteen years she served faithfully and
well at the Mercy Hospital at Davenport, until she
had become the assistant mother superior.
Her good qualities and executive and administra-
tive ability were recognized by the bishop of the dio-
cese and Sister Mary Philomene was sent to Des
Moines, to found the Mercy Hospital, which was to
be a branch of the Davenport house.
The first start was made in the place now known
as Hoyt Sherman Place. Twenty beds were in-
stalled and Mother Superior Sister Philomene be-
gan her work.
Within a short time this structure became too
small and the mother superior had visions of a larger
building, in which not one score, but several score of
sick could be cared for.
A campaign was started and the east wing of the
present structure was the result.
This in time was outgrown and the central portion
of the building was added.
So faithfully did Sister Philomene work, that when
a few years ago the hospital again became too small
for the work, the west wing was subscribed for in a
short time, and became a reality, towering high with
the other and older wings.
Six years ago, with her dreams of a large hospital
realized. Sister Philomene was rewarded by Bishop
Dowling, when he made the Mercy Hospital an in-
dependent home and she was named as the reverend
mother superior, with full charge.
Dr. and Mrs. J. Fred Clarke entertained the new
class of nurses of the Jefferson County Hospital
with a Christmas dinner at their home. Christmas
greenery, candles and attractive favors gave a festive
air to the occasion. The guests included the Misses
Barbara Nofr, Helen Frazier, Mary Linder, Gladys
Fulton, Fay James and Mildred James, members of
the class.
Sigourney now has a hospital. For a number of
weeks the process of overhauling and practically re-
building the interior of the Merchants Hotel building
and fitting it for the purpose of a good up-to-date
hospital has been going on.
Opening of New Henry County Hospital
Between five and six thousand people, men, women
and children passed through the Henry County Hos-
pital during the two public reception days, Saturday
and Sunday, December 10 and 11. Clear warm days
and good roads brought people here from all over
the first district. Scores of physicians and nurses
came in cars to look over the new hospital, which
has been declared by the profession to be the most
perfectly appointed, most modern in equipment and
economical in arrangement and beautiful in furnish-
ings of any hospital, large or small, in the Middle
West.
On Friday, December 9, the doctors of the county
made a thorough and most exhaustive examination
of the institution and later while in session discussed
the various features of the project with the utmost
freedom. The general sentiment of the physicians
seemed to be that the trustees had erected and fur-
nished a building that was a creditable, efficient, prac-
tical and all that could be expected of a small hos-
pital. The general arrangements, the design, the
equipment and the furnishings were approved as
correct. Visiting surgeons openly stated that in
their opinion the Henry County Hospital was the
best constructed, the best designed, equipped and
furnished of any hospital in the state irrespective
of size of hospital or size of community and that
78
JouRN = L w State Medical Society
[February, 1922
the taxpayers had an institution : ’ ’ ey coulu
in every way be proud and satis*;eil. Dr. Brockman
of Ottumwa was especially pleased with the hospital
and Dr. Tombaugh of Burlington was equally com-
mendator}”^ of the building.
One of the most successful surgical clinics ever
held in Waverly occurred Saturday, November 26 at
Mercy Hospital at Waverly, when practically all the
members of the Iowa Clinical Surgeons’ Association
met in this city for their regular clinic. These sui'
geons, many of whom are noted men in the profes-
sion, came from all parts of the state to attend the
Waverly meeting.
On this occasion all the actual surgical work was
done by Dr. W. A. Rohlf of this city, but he was
assisted by several of the other local men in giving
anesthetics, etc.
During the session of the clinic, which lasted from
8:00 o’clock A. M. until noon, ten major operations
and one minor operation were performed.
At noon the party took luncheon at the Fortner
Hotel and after spending the afternoon in our city,
they journeyed by auto to Waterloo, where at 7:00
o’clock they enjoyed a lobster dinner at the Hotel
Russell-Lamson.
Mercy Hospital, Waverly
A pleasant Christmas party was given by the
Sisters at Mercy Hospital, Saturday evening, De-
cember 24, 1921, for the nurses and staff.
Gift to Hospital
The Eldora Hospital received from J. E. Booth,
$10,000 in memory of his wife, and the name of the
hospital will be changed to the Eldora Booth Me-
morial Hospital.
PERSONAL MENTION
Dr. Julia Hill of the Grinnell Clinic, leaves for
Chicago where she will take a three months’ post-
graduate course in pathology under the direction of
Drs. H. Gideon Wells and E. R. Recount. During
her absence her work will be carried on by Aliss
Jeanette Lowrey, who has recenth’ completed a
course in laboratory training under Dr. Glomset of
Des Moines.
Robert Burns Armstrong, at one time connected
with newspapers in Des Moines and afterwards with
the Record-Herald of Chicago, has been elected
president of the National Press Club at Washington,
succeeding and defeating George Authier, another
Iowan. Mr. Armstrong is a son of Dr. Robert B.
Armstrong, a leading physician of this county, living
at Polk City. Robert became private secretary to
Secretary Leslie M. Shaw, when the latter was at the
head of the treasury department, and was afterwards
appointed by President Roosevelt assistant secretary
of the treasury. Of late he has been in business at
Los Angeles, California, and now represents the
Los Angeles Times at Washington city.
Dr. G. H. Sumner, secretary of the state board of
health for the past twelve years, was removed from
office and Rodney P. Fagan of Des Moines, who
was division surgeon of the 34th Division A. E. F.,
was named as his successor. The state appointing
board consists of the governor, secretary of state
and auditor of state. Their official statement in dis-
missing Dr. Sumner reads as follows: “Whereas, in
the judgment of the appointing board of the state ,
board of health, the health interests in the state re-
quires and demand that change be made in the sec-
retary and executive office of the state board of
health and that in the judgment of the appointing
board, good and sufficient cause exists for such ac-
tion.’’ “Therefore be it Resolved, that effective De-
cember 31, 1921, Doctor Guilford H. Sumner, present
secretary and executive officer of the said board, be
relieved of the duties of said position and that Dr.
Rodney P. Fagan, late lieutenant colonel of the med-
ical corps of the Thirty-fourth Division overseas in
the World War, be appointed as his successor.”
Dr. Hugh Jenkins who has been in active practice
for over forty years at Preston, accompanied by his
family, is spending the winter months at Tucson,
Arizona, for a much needed period of rest and re-
cuperation.
Dr. Merrill M. Myers of Des Moines has just in-
stalled in his office a late type Hindle electro-cardio-
graph. This is the second electro-cardiograph to be
installed in Iowa.
Dr. and Mrs. A. S. Harper, Dr. and Mrs. G. G.
Ward, Dr. and Mrs. J. B. O’Connor and Dr. and
Mrs. D. L. Patterson of Oelwein, were hosts and
hostesses to the Doctors and Dentists’ Club Monday
evening, November 28, at the home of the latter on
Second avenue East. A delicious six o’clock dinner
was enjoj-ed from a table centered with chrysan-
themums. Music and dancing formed the diversion
of the evening until a late hour. Dr. Jeanette
Throckmorton of Des Moines who had lectured to
the Parent-Teachers Association in the afternoon,
was an honored guest.
Relatives and friends in this city have received
word of the birth of a daughter to Dr. and Mrs.
Joseph P. Cochran in far away Tabriz, Persia, where
Dr. Cochran is a medical missionary. The mother
will be better known to Storm Lake as Miss Bernice
Gregg. The little Persian has been named Dorothy
Ann and she was born on Sunday, November 28, the
cable having been received Monday. — Storm Lake
Pilot.
Dr. Dean Hill Osborne of Kalona, has been ap-
pointed to the post of chief surgeon in a new clinic
at Albert Lea, Minnesota. He is a 1910 graduate of
the S. U. I. College of Medicine; while here he
acted as assistant football coach. During the war
Dr. Orborne served over seas with the medical corps
of the 324th Field Artillery.
Dr. Tilden, college physician at Ames, during the
last fourteen years, will succeed Dr. Osborn, as a
Kalona practitioner.
The annual meeting of the Physicians’ Club of
VoL. XII, No. 2]
Journal of Iowa State Medical Society
79
II
I
I
Keokuk will be held at the Y. W. C. A. Officers
will be elected at this meeting. Dr. Tom B. Throck-
morton, secretary of the Iowa State Medical So
ciety, will be present as the club’s guest. He will
read a paper on Making of a Neurological Diagnosis
All physicians of the neighborhood will be welcome
to attend this meeting.
Dr. Orrie Christ of Ames, who with his bride of
a few days, left here a few months ago for Vienna,
Austria, where he is taking an advanced course in
medicine in the university there, has been honored
by the selection as vice-president of the American
Medical Association there.
Joseph W. Rountree of Waterloo has started ac-
tion to recover $6,000 from an insurance company
to cover the loss of radium lost while a patient was
being treated at a local hospital.
Pamphlets and official notices were sent out by
the Northwestern naming the physicians and their
territory for the coming year. The notifications are
that Dr. A. B. Deering and Dr. A. B. Fagerstrom
are to be the company physicians for this district.
The territory to which Dr. Deering is liable to call
is given as between Boone and Glidden, while Dr.
Fagerstrom will have the territory between Boone
and Ames. The offices are the same the men have
held with the exception that the territory of Dr.
Deering is enlarged.
Dr. J. F. Auner of Des Moines was in attendance
upon the annual clinic of the Chicago Dermatological
Society held in Chicago January 18 and 19.
MARRIAGES
! . .
I Dr. Edwin G. Bannick of Wilton Junction and Miss
I Vesta Meredith of Atlantic were married September
I 21, 1921.
j Mr. and Mrs. J. C. Ashton, 1051 West Twenty-
I third street, announce the marriage of their daughter,
Mary, to Dr. Warren E. McCrary of Lake City, Iowa,
' which took place November 28 in Clarion, Iowa.
OBITUARY
On Friday evening at 10:30 o’clock, December 16,
Dr. Gilbert Baldwin of Ruthven died. His death
came as a shock to the community in which he
lived and to the large circle of acquaintances both
in the medical profession and without.
Dr. Baldwin had had a mitral regurgitation for
some years. Compensation had been complete. At
about 6 P. M. of the day of his death he had cranked
his automobile engine which was slow in starting.
Soon after walking to supper he felt sick and called
for his partner. Dr. H. M. Huston. It is thought
that Dr. Baldwin died of an acute dilatation of the
heart.
Dr. Baldwin was an active man and never spared
himself in the interest of his large group of patients.
He was one of the best known men of Palo Alto
county. He died in his fortieth year of practice at
Ruthven. He was public spirited to a large degree
and entered into the activities of his community with
a zeal which endeared him to all those with whom he
came in contact. Though maintaining a general prac-
tice of medicine and surgery, he was alive to the
advances in his profession. He was an ardent sup-
porter of the local medical societjes and of the so-
cieties of larger extent.
Gilbert Baldwin was born in Minnesota on Oc-
tober 23, 1859 and in consequence was just past his
sixty-second birthday. After growing to manhood
he attended the Washington University at St.
Louis, graduating from the medical department in
1882 after which he started the practice of medicine
in Ruthven. For two years he was in partnership
with Dr. Livingston and for the last thirty years
has been a partner of Dr. Huston.
In 1890 he united in marriage with Miss Carrie
Larson and to this union one son was born. Perry G.
In 1904 he was united in marriage to Miss Bessie
Larson and they have continued to make their home
in Ruthven.
The funeral was held Monday, December 19.
About thirty physicians from the surrounding coun-
ties attended in a body.
MILWAUKEE COUNTY MEDICAL SOCIETY,
MILWAUKEE, CONTRIBUTES TO TRI-
STATE FOUNDATION FUND
The executive committee of the Milwaukee County
Medical Society, courtesy of Drs. Edwin Henes, Jr.,
E. A. Fletscher, W. T. McNaughton, J. Gurney Tay-
lor, J. J. Seelman and J. L. Yates report a donation
of $317.25 from the Milwaukee County body to the
Foundation Fund of the Tri-State District Medical
Society of Illinois, Iowa and Wisconsin. The amount
was voluntarily contributed to the endowment fund
for the “support of the splendid purpose for which
the Tri-State District Medical Association was or-
ganized.”
The Milwaukee County Medical Society is the first
official body in the three states to contribute to the
fund although a large number of Wisconsin physi-
cians are individual subscribers.
H. G. Langworthy, Dubuque,
Cbrm. Foundation Fund.
BOOK REVIEWS
THE SPLEEN AND SOME OF ITS DISEASES
By Sir Berkley Moynihan of Leeds, Eng-
land, 129 Pages with 13 Full Page Diagrams.
W. B. Saunders Company, 1921. Price,
Cloth, $5.00 Net.
The spleen is coming to be recognized in its re-
lation to other organs aside from being an important
organ on its own account. When operations on ab-
dominal organs came to be recognized as a legitim-
ate undertaking, the spleen was removed for reasons
relating entirely to itself, as serious injuries, twisted
7.
1
80
JouKXAL OF lov • State Medical Society
[February, 1922
pedicle or incised for abscesses or cysts, a. ' 'e-
moved for enlargements. In later years for ci. sis
of the liver, pernicious anemia and he iol>ti< ; in-
dice; therefore, the spleen has become • oi t - of
greatly increased interest.
Surgeons and pathologists are turning to the
spleen for a solution of some of the mysteries on-
nected with diseases of heretofore unknown o. gin,
and believed to be incurable, chiefly relating t' the
blood. Communications have come from certain
clinics which seem to show that an inter-relation
exists between the liver and spleen not hitherto sus-
pected. Sir Berkley Moynihan of wide surgical vi-
sion in his Bradslaw lectures before the Royal Col-
lege of Surgeons of England has brought to the at-
tention of the profession the accumulated facts and
theories of the liver-spleen system. In the first
chapter an anatomical outline is given. In the second
chapter, surgery of the spleen. There are presented
some of the early operations for the removal of the
spleen in 1549. In 1898 records were collected of
274 splenectomies with 170 recoveries. At the Mayo
Clinic 243 splenectomies have been made for disease
with twenty-six hospital deaths. These are divided
into five groups: Splenectomies for Splenic Anemia;
for Pernicious Anemia; for Myelogenous Leukemia;
for Hemolytic Icterus; for Septic Splenomegalias.
Following is a discussion of the Function of the
Spleen; the Pathology of Splenic Disease; which
brings the author to the main question; the Clinical
and Associated Phenomena of Splenic Disease, and
Percy statistics and observations, with such conclu-
sions as the philosophic mind of Sir Berkley may
furnish.
In Chapter 13 is a discussion on the Liver in Some
of Its Relation to the Spleen. This is the concluding
chapter of this important contribution.
PRINCIPLES OF HYGIENE
The new (7) Edition. A Practical IManual
for Students, Physicians, and Health Offi-
cers. Bj' D. H. Bergey, M.D., Dr. P. H.,
Assistant Professor of Hygiene and Eac-
teriolog}''. University of Pennsylvania. Sev-
enth Edition, Thoroughly Revised. Octavo
of 556 Pages, Illustrated. Philadelphia and
London. W. B. Saunders Company, 1921.
Cloth, $5.50 Net.
In this latest edition of a work first published in
1901, Dr. Bergey has endeavored by rewriting some
and revising other parts, to bring this presentation
of the subject up to date.
He considers that hygiene treats not only of those
laws by which health is preserved, but also those
which tend to raise the standard of health generally.
This would necessarilj" give to the subject a wide
field for all factors must therefore be considered
which have any tendency to alter living conditions
either favorably or unfavorably, in all sorts of en-
vironments and under all sorts of climatic condi-
tions. It must consider racial and social differences.
the changing situations in peace and war, and dis-
tinguish between these factors as applied on the one
hand to the individual, and on the other to the
community.
These things the author treats of in a thorough,
comprehensive manner, and not only as regards hy-
giene, strictly defined as the knowledge of how
health is affected, but also deals with sanitation, the
art of producing such conditions as are conducive
to continued or better hygiene.
In the introduction, the causes of disease are con-
sidered in a general way, and a short outline is
given of the beginnings of modern hygiene through
the observations of men interested in medicine,
science, and philanthropy.
An idea of the thoroughness with which the author
has covered his subject may be gained from the head-
ings of his chapters: Air; Ventilation; Heating;
Water and Water Supply; Sewage; Garbage; Food
and Dieting; Exercise; Clothing; Personal Hygiene;
Industrial, School, Military and Naval Hygiene; Soil;
Habitations; Vital Causes of Disease; Disinfection;
Quarantine; Vital Statistics.
An appendix gives various rules for conversion of
metric into other units, of measurement.
Our increase of knowledge along lines of hygiene
and sanitation and the increased interest of the
public in these matters, from which has developed
a demand for public servants better trained to serve
as public health officers, has been met in part by the
offering of courses in some schools leading to the
degree of doctor of public health. However, an in-
crease iij general knowledge of hygiene such as may
be obtained from works like that of Dr. Bergey, will
be of aid in providing an intelligent public for the
health officer to serve, to their mutual advantage. —
Major H. R. Reynolds, U. S. Public Health Service.
DISEASE OF THE SKIN
By Richard L. Sutton, M.D., Professor of
Diseases of the Skin; University of Kansas
School of Medicine; Former Chairman of
the Dermatological Section of the American
Medical Association; Assistant Surgeon,
United States Navy, Retired; Dermatologist
of the Christian Church Hospital. With 969
Illustrations, and Eleven Colored Plates.
Fourth Edition, Revised and Enlarged. C.
V. Mosby Company, St. Louis, 1921.
This book of 1132 pages with its numerous illus-
trations is of very great value to the medical pro-
fession. Probably no subject offers so many diffi-
culties to the general practitioner as diseases of the
skin, yet the patient brings his ailment in full sight,
and expects a definite diagnosis and some form of
successful treatment. It is not enough that the phy-
sician gives a hasty glance to the diseased surface,
names some disease he happens to remember, pre-
pares some medicine, which probably has no effect,
and directs the patient to return.
(Continued on Adv. Page xvi )
Journal of Iowa State Medical Society
XV
A RlooHle^^ FielH is promptly produced by the appH-
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Suprarenalin Solution, 1:100.0
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Ischemia follows promptly the use of
1:10000 Suprarenalin Solution slightly
warmed (make 1 : 10000 solution by adding
1 part of Suprarenalin Solution to 9 parts
of sterile normal salt solution).
In obstetrical and surgical work Pituitary
Liquid (Armour), physiologically standard-
ized, gives good results — ]/> c. c. ampoules
obstetrical — 1 c. c. ampoules surgical.
Either may be used in emergency.
Elixir of Enzymes is a potent and palatable
preparation of the ferments active in acid
environment — an aid to digestion, corrective
of minor alimentary disorders and a fine
vehicle for iodides, bromides, salicylates,
etc.
As headquarters for the organotherapeutic
agents, we offer a full line of Endocrine
Products in powder and tablets (no com-
binations or shotgun cure-alls).
Armour’s Sterile Catgut Ligatures are made from raw ma-
terial selected in our abattoirs, plain and chromic, regular and
emergency lengths, iodized, regular lengths, sizes 000 — 4.
Literature on Request
ARMOUR^COMPANY
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When writing to advertisers please mention The Journal of Iowa State Medical Society
XVI
NAL OF
A State Medical Society
BOOK R1 • lEWS
(Continued fron. ay Ckjj
Every case requires careful study and inquiry into
habits of living, elimination, excretions and all ques-
tions that may lead directly or indirectly to the skin
lesion. In this book may be found lines of inquiry
which draw attention to the pathology of the dis-
ease which when worked out will form a basis for
a more or less successful treatment. In the proper
place, will be found formulas that have been found
efficient when properly employed. It is a book for
study, not merel}^ for reference. A successful treat-
ment of an obstinate case of skin disease will con-
tribute more to the physician’s reputation than any
number of appendix operations. Dr. Sutton has been
fortunate in presenting a difficult subject in an at-
tractive manner.
SURGICAL ANATOMY
By William Francis Campbell, M.D., Sur-
geon-in-Chief at Trinity Hospital, Brooklyn,
N. Y. Sometime Professor of Anatomy and
Professor of Surger}"-, Island College Hos-
pital. Third Edition Revised, 681 Pages with
325 Original Illustrations. W. B. Saunders
Company 1921. Price, Cloth $6.00 Net.
The author in the preface rriodestly states that
“Only the manner of their presentation and the at-
tempt to estimate their clinical values can be credited
to the author.” This of course relates to the an-
atomic facts set forth by writers on surgical an-
atomy at various times; but the presentation is the
essential facts that determines the value of the book.
Dry anatomic facts are difficult to utilize and often
turns the student away discouraged.
An examination of this book will show that the
text and illustrations are so arranged as to main-
tain the interest of the student and surgeon to the
end. It would be quite impossible to consider the
contents in detail and we are limited to an expres-
sion of an appreciation of the value of the claim
modestl}- stated.
DISEASES OF THE SKIN
By Henrj- W. Stelwagon, M.D., Ninth
Edition, Revised with the Assistance of
Henry K. Gaskill, M.D., Attending Dermato-
logist to the Philadelphia General Hospital,
1313 Pages with 401 Text Illustrations and
Half Tone Plates. W. B. Saunders Com-
pany, 1921. Cloth, $10.00.
The ninth edition of a well known book on skin
diseases is before us. We welcome it cordially.
We realize the need the practitioner of general med-
icine has of these fine works on skin diseases. The
various popular cults that have come to afflict us
in recent years, are not activ'e competitors for the
real and difficult subjects in medicine, and if we have
a superiority over them it may be shown in the real
things in medicine. The sufferers from skin dis-
eases have something real to show and are possessed
of a real and earnest desire for relief.
■ Skin diseases are not cured by the use of lotions
and ointments; the difficulty lies deeper; it means a
scientific inquiry into many things, not merely a
reference to standard books for direct remedies,
which are good for certain things that appear on the
surface, but a real and detailed study, directed by
the recorded knowledge and experience of experts.
The position held by Stelwagon on skin diseases
for many years should impel the student of medicine
who has no controversy with strange medical no-
tions, to keep this book in easy reach for study. He
must realize that the public have no real interest in
medicinal controversy, only in securing relief from
distressing and troublesome afflictions, by an in-
quiry into the causes of their sufferings and a meas-
ure of relief. It is not difficult to explain the reason
for delay in the cure, if the patient is convinced that
the physician is in earnest, seeking the remedy
whether medical or otherwise, he wdll cooperate.
A TREATISE ON CATARACT
Donald T. Atkinson, M.D., San Antonio,
Texas; 150 Pages, 29 Plates; New York City.
The Vail-Ballon Company.
This well written book is printed in large type
and contains good illustrations, many of which are
reproductions of photographs. These photographs
unfortunately do not show the finer details, the dia-
gramatic drawings show them better.
If we were to offer adverse criticism it would be
that the subjects written about are discussed too
briefly. For example the description of the anatomy
of the lens and capsul is very brief. A short para-
graph devoted to the embryology mentions that the
lens is derived from cuticular epiblast, but does not
mention the origin of the lens capsul. There is no
statement of histology or microscopic pathology.
There are three pages devoted to the responsibility
of the general practitioner in the diagnosis of senile
cataract. The author believes that the general prac-
titioner should be able to diagnose and to advise
when the operation should take place.
A long paragraph describes the fixation forcepts
and the position in which it should be held, but it
does not state where in relation to the limbus the
forcepts should be applied. The illustration show 't
applied away from the limbus, this, according to
many leading authorities, does not give good fixa-
tion.
The book contains no new material, but it brings
together and states briefly the combined experience
of the profession with a few added points at which
the author has arrived by study and long observation
E. P. Weih, M.D.
(Continued on Adv. Page xxxiii)
JouRi^AL OF Iowa State Medical Society
xxvii
CO<^IM~rY IVIEIOIOAL- SOOIEZ'T'V OF’F'ICERS
I I
COUNTY PRESIDENT SECRETARY
□
□
Adair E. O. Reynolds, Greenfield....
Adams Mark E. Johnson, Corning....
Allamakee Otto O. Svebakken, Waukon...
Appanoose G. F. Severs, Centerville
Audubon K. A. Jacobsen, E.xira
Benton
Black Hawk T. F. Thornton, Waterloo
Boone L. A. Bassett, Boone
Bremer H. Graening, W'averly
Buchanan Chas. W. Tidball, Independence
Buena Vista
Butler D. N. Reeve, Allison
Calhoun \ Q Norton, Rockwell City...
Carroll -Sidney D. Martin, Carroll
Cass R, L. Barnett, Atlantic
Cedar p. J. Laughlin, Clarence
Cerro Gordo T. A. Burke, Mason City
Cherokee R. C. Sebern, Cherokee
Chickasaw L. P. Reich, Fredericksburg....
Clarke H. L. Hollenbeck, Osceola
Clay E. E. Munger, Spencer
Clayton S. C. Ainsworth, Volga
Clinton Chas. T. Bigelow, Clinton
Crawford H. D. Jones, Schleswig
Dallas-Guthrie A. J. Ross, Perry
Davis Claude A. Powers, Pulaski
Decatur O. H. Peterson, Lamoni
Delaware Bert H. Byers, Manchester....
Des Moines J. S. Cooper, Burlington
Dickinson C. M. Coldren, Milford
Dubuque C. A. Kearney, Dubuque
Emmet Maurice E. Wilson, Estherville
Fayette C. D. Mercer, West Union....
Floyd R. W. Sleeter, Rockford
Franklin W. R. Arthur, Hampton
Fremont Wni. Kerr, Randolph
Greene B. C. Hamilton, Jr., Jefferson..
Grundy H. V. Kahler, Reinbeck
Hamilton E. W. Slater, Jewell
Hancock- Winnebago. .R. S. Fillmore, Corwith
Hardin W. W. Van Tiger, Eldora
Harrison F. H. Hanson, Magnolia
K^tiry f \V. Gardner, Mt. Pleasant...
Howard J. W. Jinderlee, Cresco
Humboldt
Tda Giles C. Moorehead, Ida Grcve.
.Arnold C. Moon, Williamsburg.
Jackson R. PI. Lott, Maquoketa
Jasper J. L. Taylor, Monroe
Tefferson M. C. Carpenter. Fairfield
■Johnson T. H Wolfe, Iowa Citv
Jones yp McGarvey. Monticello
Keokuk Tohn Maxwell, What Cheer....
Kossuth Pierre Sartor, Titonka
Cfs Oliver T. Clark, Keokuk
J A. W. Erskine, Cedar Rapids..
Louisa T. H. Chittum, Wapello
A. L. Yocum, Jr., Chariton....
' FO'i Tohn E. North, Rock Rapids....
Madison M. L. Pindell. Winterset
Mahaska R, Q, Jerrell. Oskaloosa
Marion T. J. Svbenga, Pella
Marshall R, E. Kevser, Marshalltown,...
^^|Bs Edgar Christy, Hastings
Mitchell T. S. Walker, Riceville
Monona E. J. Bild. Mapleton
Monroe Geo. A. Jenkins, Albia
Montgomery Louis A. Thomas, Red Oak
Muscatine W. H. Johnston, Muscatine....
O’Brien i..F. W. Cram, Sheldon
O^eola Tames B. Padgham. Ocheyedan.
Bage B. S. Barnes, Shenandoah
Palo Alto T. W. Woodbridge, Cylinder....
Plymouth George Alattison, Akron
Pocahontas T. H. Hovenden, Laurens
Polk A. P. Stoner, Des Moines
Pottawattamie M. E. O’Keefe, Council Bluffs.
PoweSiiiek E. J. Ringena, Brooklyn
Ringgold Wm. Horne. Mount Ayr
Sac F. H. McCray, Schaller
Scott B. H. Schmidt, Davenport
Shelby V. J. Myers, Defiance
Sioux T. E. McCaughan, Ireton
Story Earl B. Rush, Ames
Tama T. A. Pinkerton, Traer
Taylor B. TI, Miller, Blockton
Union J. G. Macrae, Creston
Van Buren C. N. Stevenson, Milton
Wapello W. E. Anthony, Ottumwa
Warren W. E. Sperow, Carlisle
Washington E. E. Stutsman, Washington...
Wapme A. E. Davis, Seymoure
Webster W. F. Carver, Fort Dodge
Winneshiek A. E. Conrad, Decorah
Woodbury W. J. S. Cremin, Sioux City...
Worth S. S. Westley, Manley
Wright H. P. Walker, Clarion
. . . J. A. Harper, Greenfield
. . . .J. II. Wallahan, Corning
J. W. Thornton, Lansing
Wm, W. Syp, Centerville
. . . . R. F. Childs, Audubon
....G. R. Woodhouse, Vinton
Edward Molloy, Waterloo
. . . .C. A. Noland, Boone '
F. J. Epeneter, Denver
Robt. A. Buchanan, Independence
....Edgar F. Smith, Storm Lake
.C. F. Roder, Aredale
....Lena A. Beach, Rockwell City
Jessie B. Hudson, Carroll
. . . .M. F. Stults, Wiota
....Paul M. Hoffman, Tipton
. ...W. L. Diven, Mason City
i . . .F. B. E. Miller, Cherokee
Paul E. Gardner, New Hampton
....Con R. Harken, Osceola
. . . T. H. Johnston, Spencer
. . . . James C. Brown, Littleport
,...L. K. Fenlon, Clinton
....J. J. Meehan, Denison
....S. J. Brown, Panora
....Henry C. Young, Bloomfield
....C. H. Mitchell, Leon
H. A, Dittmer, Manchester
....G. H. Steinle, Burlington
Chas. S. Shultz, Spirit Lake
....II. E. Thompson, Dubuque
....W. E. Bradley, Estherville
....D. W. Ward, Oelwein
. . . .R. H. Woodruff Charles City
E. D. Allen, Hampton
A. E. Wanamaker, Hamburg
....John R. Black, Jefferson
....L. H. Carpenter, Grundy Center
....M. B. Galloway, Webster City
....H. F. Thompson. Forest City
....W. E. Marsh, Eldora
....H. N. Anderson. Woodbine
....E. A. Stewart Mt. Pleasant
□
W. C. Hess, Cresco
....Asaph Arent, Humboldt
....Chas. S. Stoakes. Battle Creek
....T.. S. Dietrich. Marengo
....D. N. Loose, Manuoketa
,...W. T5. Anspach, Colfax
....Fhas. Ricksher, Fairfield
. . . - T awson G. Lowrey, Iowa City
....Thos. M. Redmond, Monticello
....M. E Kemn. Sigourney
.. .M T, Kenefick, Algona
....William Rankin. Keokuk
. . . .Rov C. Alt. Cedar Rapids
.O. W. McGrew. Columbus Junction
!!!!Frank C. Scott. Chariton
....Geo. H. Boetel. Rock Rapids
... Robt. R. Davisson, Winterset
Francis A. Gillett. Oskaloosa
....Corwin S. Cornell, Knoxville
...,F. L. Wahrer. Marshalltown
. . . .H. C. Yates, Emerson
. . . .Guy A. Lott, Osage
. . . .W. W. Gingles, Castana
....J- B. Hungate, Hiteman
....Gladvs A. Cooper, Red Oak
....W. W. Potter, Muscatine
. . . .J. W. Myers, Sheldon
,...F. P Winkler, Sibley
....M. O. Brush, Shenandoah
. . . .H. L. Brereton, Emmetsburg
. . . ,M. J. Joynt, Le Mars
. . . G. A. Everson, Plover
....H. E. Ransom, Des Moines
....A. A. Robertson, Council Bluffs
Edwin E. Harris, Grinnell
.... Samuel Bailey, Mount Ayr
...,W. J. Findley. Sac City
....W. E. Foley, Davenport
Jay D. Dunshee, Harlan
....A. F. H. deLespinasse, Orange City
....B. G. Dyer, Ames
....A. A. Crabbe, Traer
. . . .A. E. King, Blockton
....H. A. Childs, Creston
....Chas. R. Russell, Keosauqua
. . . .Harry W. Vinson, Ottumwa
....M. L. Hooper, Indianola
....C. A. Boice, Washington
...,G. H. Sollenbarger, Corydon
Thos. J. Dorsey. Fort Dodge
.Milton D. Jewell. Decorah
E. D. Tompkins, Clarion
.R. M. Waters, Acting Secretary, Sioux City I I
.E. H. Dwelle, Northwood I I
NiiiimiiMmiiMiiiiiiiiimiiiiimuiiiiMiiiMMiiiiiimiiiiiiiiNiiimMiiiMUiiiiMmMiiniii'mNnmiiiiimiiiKiiiii
iiiiiiMitm
xxviii
Journal of IoviA State Medical Society
BOOK REVIE VS ^
(Continued from Adv. U.-ge xvi)
THE MEDICAL- CLINICS ■ 'E NOk i'H
AMERICA
Chicago Number, July, 1921. tund-
ers Company. Price, $12.00 Bi
A considerable variety of cases are discussed in
this number of which we will mention a few.
Dr. Charles S. Williamson presents four patients
who represent an important subject; pericarditis
with effusion, a condition which is overlooked in a
hurried examination but which should present no
great difficulties in diagnosis. An important subject
is presented by Dr. Isaac Abt, a condition which may
seriously influence the future of the new born infant,
meningeal hemorrhage; this condition sometimes oc-
curs in difficult, delayed or instrumental delivery.
NEW AND NON-OFFICIAL REMEDIES
During December the following articles have
been accepted by the Council on Pharmacy and
Chemistry for inclusion in New and Non-official
Remedies;
The Abbott Laboratories:
Neocinchophen — Abbott.
Powers-Weightman-Rosengarten Co. :
Mercury and Potassium Iodide — P. W. R.
Schimmel and Co.:
Oil of Cypress — Schimmel and Co.
E. R. Squibb and Sons:
Liquid Petrolatum — Squibb.
Food Allergens — Squibb.
Pollen Protein Allergens — Squibb.
Animal Epidermal Extract Allergens — Squibb.
Bacterial Allergens — Squibb.
Winthrop Chemical Co.:
Chaulmestrol.
Non-proprietary Article;
Chaulmoogra Oil.
Change of Agency: Cresatin — The Council has
directed that the description of Cresatin (New and
Non-official Remedies, 1921, p. 94) be revised to
show that the name has been changed to Cresatin —
Dr. N. Sulzberger and that it is manufactured by the
Intravenous Products Company of America, Inc.
WANTED — A competent physician and surgeon to locate in a good Iowa county seat town of about
5000 population; excellent schools; office well located, established ten years; fixtures, instruments and
drugs. Address X, care this Journal.
Fat Soluble A and Rickets
“In cases where rickets or growth failure or xero-
phthalmia are already well established, a daily dose
of cod-liver oil is essential to all other procedure.”
What modern science has done to assure pure
milk, it has also done for cod-liver oil.
The “S. & B. PROCESS”
Clear Norwegian (Lofoten) Cod-liver Oil
is pure oil from selected, healthy livers of
fresh caught True Gadus MorrhuaCf
that may be prescribed with the same
confidence that you would certified milk.
Produced in Norway
and refined in America.
Liberal samples to
physicians on request.
SCOTT & BOWNE, BLOOMFIELD, N. J.
When writing to advertisers please mention The Journal of Iowa State Medical Society
lEMt JToumal of tfje
Jlotua ^tate jlHeiiual ^cietp
VoL. XII
Des Moines, Iowa, March 15, 1922
No. 3
A CLINICAL STUDY OF FIFTY CASES OF
PNEUMOTHORAX*
Willis S. Lemon, M.D.
Section on Medicine, Mayo Clinic, Rochester, Minnesota
Arlie L. Barnes, M.D.
Fellow in Medicine, The Mayo Foundation, Rochester, Minnesota
In 1803, Itard coined the term pneumothorax to
describe the condition of air free within the
pleural space. He was able to demonstrate its
presence in five necropsies of patients dying of
tuberculosis, and he associated the presence of air
as a complication of the disease.
It is now the centennial of Laennec’s invention
of the stethoscope and his discovery of mediate
auscultation. To him belongs the credit of fir.st
recognizing pneumothorax during life. His de-
scription of physical signs, and his classification
according to etiology were so complete that little
has been added thereto. He also first interpreted
the succussion splash to be due to the combined
presence of air and fluid in the pleural space.
This diagnostic sign was described in the com-
plete works of Hippocrates of the fifth centurv,
B. C., known as “Hippocratic succussion.” The
authorship is questionable, and it seems certain
that Hippocrates and his contemporaries misun-
derstood the significance of the sign, being misled
because of the universal belief that air was nor-
mally present in the pleural cavity.
During the early part of the nineteenth century,
the value of Auenbrugger’s discovery of percus-
sion, and of Laennec’s auscultation had been
properly evaluated, and in those years a fineness
of description and an accuracy of examination
developed that we would do well to imitate. To
the great clinicians of that day accurate histories
and painstaking examinations were necessarily of
primary importance. Few laboratory tests could
contest their place in diagnosis and they had not
the x-ray to tempt them from clear thinking and
accurate work.
Pneumothorax has acquired a new interesi
since Forlanini, in 1888, and Murphy independ-
*Read before the Seventieth Annual Session. Iowa State Medical
Society, Des Moines, Iowa, May 11, 12, 13. 1921.
ently, in 1898, utilized artificial pneumothorax
in the treatment of certain types of tuberculosis.
The method was coolly received for a few years,
but has recently enjoyed a vigorous revival.
Again during the Great World War it was
found that not all of the ydiysiology of pneumo-
thorax was understood.
Many lives were sacrificed before the problem
of high mortality following early operation in
empyema was solved.
Even today with regard to the treatment of the
condition and its complications, opinions are far
from uniform. This is especially true of the
cases presenting urgent symptoms.
The fifty cases in this series are discussed for
the purpose of calling attention to the need of
greater utilization of common methods of physi-
cal diagnosis in order to point out certain defects
in our knowledge of the condition, to indicate dis-
tressing complications of certain methods of
treatment, and, finally, to reach rational methods
of treatment based on our experience and the
consensus of opinion of men who have had op-
portunities of dealing with this class of case.
The Physiology of the Chest as Applied to
P N EU M OT II OR. A. X
Physiology fails in many respects to account
for the jihenomena of pneumothorax since each
case is in a measure a law unto itself. Howeve’*,
certain physiologic principles are basic and should
always be kept in mind in interpreting the indica-
tions of this condition.
N'ormal negative intrapleural tension depends
on, ( 1 ) the fact that at the first respiration after
birth, “the thoracic cage expands more quickly
than the lungs, so that the latter become
stretched” by the atmospheric air entering
through the respiratory passages, and (2), the
fact that the lungs thus stretched tend, by virtue
of their elastic tissue, to recoil. Thus when in-
spiration occurs the lungs are more expanded and
negative intrapleural tension is increased, and on
expiration, the intrapleural tension becomes les-
sened. The force required to keep an elastic band
taut depends directly on the degree of stretching.
82
Journal of Iowa State Medical Society
[March, 1922
and decreases as it returns to normal dimensions.
Thus we have a respiratory fluctuation in intra-
pleural tension, which determines the movement
of air in and out of the lungs. As IMcLeod re-
marks “the thorax does not expand on inspiration
because air rushes in, but air rushes in because
the thorax expands.” He gives 5 m.m. mercur}'^
on expiration and 10 m.m. mercury on inspiration
as the normal intrapleural tension in man. Aron
in thirty-six observations on a normal person
found the average intrapleural pressure on ex-
piration to be -3.02 m.m. mercur\' and on inspira-
tion — 1.65 m.m. mercury.
In studying pressure in necropsies following
various diseases we found a negative pressure. If
the respiratory passages are blocked and the
thorax expands the intrapleural tension may be
as low as -80 m.m. mercury.
The mediastinum in the normal subject is a
mobile structure held in position by the traction
of the elastic tissue of the lungs exerting pull in
opposite directions. If open pneumothorax is in-
duced the lung on that side is collapsed and its
tendency to elastic recoil is satisfied. The condi-
tions determining the coaptation of the pleural
surfaces on the opposite side remain unchanged
and the elastic recoil of the sound lung is partially
satisfied by a displacement of the mediastinum
toward the sound side. ^Moreover, respiratory
fluctuation of the intrapleural pressure on the
sound side occurs with a consequent variation of
the tension exerted on the mediastinum and a cer-
tain amount of movement of the latter with each
respirator}' phase. Graham and Bell from expe-
riments on dogs, found that both lungs become
equally collapsed when a unilateral open pneumo-
thorax is produced. They are careful to apply
this observation only when the mediastinuni is un-
affected by disease. Clinical and surgical obser-
vations make it doubtful whether this holds in
man, due probably to the greater fixity of the
diaphragm in the latter. The mediastinum of the
dog is a much less rigid structure than in man,
and is not imperforate; its rigidity more nearly
corresponds to that of the infant. In this con-
nection the remarkable rigidity caused by chronic
inflammatory disease should also be remembered.
In open pneumothorax the dyspnea depends, other
things being equal, on the degree to which the
elastic recoil of the two lungs is satisfied. It
depends on the open side on the strength and
extent of the adhesions that prevent the col-
lapse of the lung. In the absence of adhesions
on the open side the degree of the lung’s col-
lapse on the sound side depends on the fixity
of the mediastinum. In cases occurring suddenly
in which no adhesions exist, the respiratory ex-
cursions of the mediastinum and the change in
intrathoracic pressure combine to interfere with
the normal circulation and add to the gravity of
symptoms. Hazard is especially great in cases
in which the tidal air approaches the vital capac-
ity, as Graham and Bell have pointed om.
An opening in the chest wall at least as large as
a cross section of the trachea must next be con-
sidered. It might be supposed that in this condi-
tion the lung would collapse completely and so
remain, yet this is not necessarily true, for West
observes that it is not an uncommon experience
on opening the chest for drainage of an em-
pyema cavity to find that the lung which has been
completely collapsed by the effusion expands as
soon as the pus is evacuated, nearly approximat-
ing the chest walls immediately after operation.
This phenomenon has been repeatedly demon-
strated in our own experience. In one instance
when operating for the removal of mediastinal
tumor, cough and deep breathing made it difficult
to keep the lung within the thorax. West ex-
plains the phenomena he describes : “The air in
the tubes is not subject simply to atmospheric
pressure during the phases of respiration. Dur-
ing inspiration a certain obstruction to the free
ingress of air is encountered which produces a
subatmospheric pressure in the tubes amounting
to 5 m.m. mercury. During expiration, a similar
obstruction to the free egress of air is met pro-
ducing a pressure of 1.5 m.m. to 2 m.m. mercury
above that of the atmposphere.” He believes that
these pressure oscillations are sufficient to ex-
pand the lung at least one-half and perhaps more,
provided it is unhampered by adhesions. In oper-
ative work it is impossible to determine whether
or not on opening the chest a lung will collapse.
Lockwood believes there is less danger in an
opening large enough to admit the hand than in
small one.
In valvular pneumothorax air finds easier ac-
cess to the cavity during inspiration than issues
from the cavity during expiration. During the
early stages, pneumothorax is always more or
less valvular and as soon as the lungs become
completely collapsed the lesion becomes com-
pletely closed whether it is sealed or not. It is
quite possible that some of the grave symptoms
believed to be due to valvular pneumothorax are
in reality due to additional successive rents in the
pleura.
By subjecting the bronchial tree to a pressure
of 10 cm. of water it is possible to expand the
retracted lung in the presence of an external
pleural opening. Tuffier states that in applying
VOL.XII, No. 31
Journal of Iowa State Medical Society
83
this procedure the upper lobe expands easily, the
middle lobe less so, and the lower lobe least
so. From this he concludes that the lower lobe
has the greatest elasticity.
Means and Balboni in a study of respiration in
persons with pneumothorax, found that one lung
is as efficient as two except when the work done
calls for more than a three-fold increase in nor-
mal ventilation. They state that the only differ-
ence between normal persons and those with a
collapsed lung is that the lattter, when called on
to increase their ventilation, reach their limit a
little sooner than the former.
We are unable to reach definite conclusions
with regard to what occurs in the circulation of a
collapsed lung. Cloetta on the basis of plethys-
mographic experiments, supports the theory that
it is better to irrigate the lung during collapse than
during inspiratory expansion. Corper, Simon and
Rensch working with rabbits, and producing uni-
lateral closed pneumothorax, injected suspen-
sions of Prussian blue, scarlet red and starch in-
travenously. These substances were found uni-
formly distributed through the lungs immediately
after injection and two hours thereafter. It was
also found that the Prussian blue disappeared
uniformly, indicating that the circulation of the
two sides was maintained equally. This finding
is supported by our clinical observation that lungs
that have remained collapsed for a long time may
regain complete function without evidence of nu-
tritional disturbance.
Etiology
The etiologic factors present in the series of
fifty cases may be tabulated as follows :
Cases
Tuberculosis
Empyema ^
Spontaneous pneumothorax (cause unknown) 6
Bronchial fistula (non-tuberculous) 3
Traumatism 3
Therapeutic measures (artificial) 3
Emphysema 2
Lung abscess 1
Thoracentesis (accidental during) (Fatal with
needle) 1
Pneumonia (complication) 1
Lymphosarcoma (complication) 1
It will be observed that the cases tabulated total
more than fifty ; two factors were present in some
of the cases and the real cause of the pneumo-
thorax could not be determined. As an example
of this overlapping, pneumothorax was induced
as a therapeutic measure in three cases, two of
tuberculosis, and one of lung abscess. Emphy-
sema was claimed to be the cause of the pneumo-
thorax in two cases in which other factors were
ruled out by careful study and in which emphy-
sema was known to be present. Five cases classi-
fied as spontaneous fulfilled Hamman’s defini-
tion except that in two cases the pneumothorax
persisted more than eight weeks. In one of these
the history made it very probable that there had
been successive attacks which prolonged the pe-
riod of absorption. We believe then an arbitrary
time limit as an absolute criterion of diagnosis of
spontaneous pneumothorax is unwarranted, and
that the findings peculiar to each case can alone
determine to which group it should be attributed.
Nineteen cases of simple pleural effusion in the
series were previously aspirated on an average of
two and eight-tenths times. It is impossible to
know how many times aspiration was responsible
for air in the pleural space. It must not be as-
sumed that the pneumothorax following aspira-
tions is necessarily due to leakage through or
about the needle. Puncture of the lung may pro-
vide the means for entrance of air from the bron-
chial system. This was clearly demonstrated in a
recent case not included in the series in which an
exploratory puncture was made. The needle
pierced the lung and at necropsy the rent was
found patent and promptly emptied the lung after
inflation. The escape of air could be detected
coming from the puncture opening when the in-
flated lung was immersed in water. It was diffi-
cult for the artist to obtain a proper view of the
lung as it became too promptly deflated. The
lung was emphysematous, and the results might
not have appeared in a normal lung. We have
repeatedly demonstrated the same condition in
lungs punctured after death, when normal elas-
ticity seems to have been interfered with.
From a study of the literature we find a gen-
eral agreement that tuberculosis is the cause of
pneumothorax in from 75 to 90 per cent of cases.
Thus Biach’s oft quoted 918 cases occurring in
the Vienna hospitals show that 715 (77 per cent)
were due to tuberculosis. West estimates that 90
per cent of cases are due to perforation of the
lung because of the breaking down of a tuber-
culous focus. Pneumothorax has been observed
as a complication of tuberculosis by Gaillard in
36 of 3415 cases (1 per cent) ; by West in 5 per
cent of cases, by Fowler and Rickman in 6.5 per
cent of 1000.
As a rule pneumothorax occurs in the cases of
tuberculosis in which the disease is advancing
rapidly, though it may occur from the rupture of
a small tuberculous nodule near the periphery of
the lung when no other tuberculous foci are dis-
coverable elsewhere in the lung. Letulle in two
84
Journal of Iowa State Medical Society
[March, 1922
excellent illustrations of pathologic specimens,
shows the method of perforation, and emphasizes
the fact that pleural adhesions are potent factors
in preventing the collapse of the lung. He states
that a single perforation is rare, and West points
out that in twenty-five perforations, two openings
occurred in four cases, and four each in two
cases; the openings occurring twice as often in
the upper as in the lower lobe and usually being
not more than from 2 to 3 mm. in diameter. In
nineteen of these twenty-five cases necropsy was
performed within a week and the opening was
still patent; in six cases the openings remained
open for from thirteen days to five months. This
shows that the opening may often persist for
months.
Pneumothorax furnishes strong presumptive
evidence of tuberculosis and, conversely, air in the
chest as a complication of known cases of pul-
monary tuberculosis must always be looked for.
We are inclined to regard pleural adhesions as
a protective process against the accident of per-
foration. If there are adhesions of sufficient
strength, pneumothorax does not exist. It occurs
at the advancing edge of the disease, probably be-
cause of the insecurity of union between the vis-
ceral and parietal pleurae. \\'e believe that if this
were not true, the complication would appear
in a very much larger percentage of cases. The
presence of apical pleurisy is a benignant process
of conservation.
Discussion of Literature
An extensive literature has accumulated around
the cases classified spontaneous pneumothorax.
Hamman has best defined this condition as “A
pneumothorax coming on in apparently healthy
individuals without ascribable cause ; resulting in
no infection of the pleura and therefore unac-
companied by constitutional symptoms, and heal-
ing rapidly and completely in a few weeks.” He
believes a duration greater than eight weeks
makes it doubtful whether the case should be de-
noted spontaneous. Zahn is quoted as ascribing
this type of pneumothorax to one of four me-
chanisms: (1) the rupture of a vesicular bleb;
(2) the rupture of interstitial emphysema bleb,
the air finally making its way to the pleura rup-
turing through it; (3) the direct tear of the
pleura by the tug of adhesions; and (4) senile
atrophy of the pleura. Hamman noted sixteen
instances in the literature of recurrences of
pneumothorax. In three of these and in one of
his own series, the recurrences were on the oppo-
site side. Abt and Straus and Meyer report two
cases of spontaneous pneumothorax with ne-
cropses which demonstrated emphysema to be the
etiologic factor. In the latter case, the pneumo-
thorax was recurrent and involved both sides for
a period of at least twenty-four da)’S. Hewlett
and Leclerc each add a similar case in which the
patient recovered, though the second side was not
involved until the first side had partially returned
to normal. These cases denote the margin of
safety inherent in the lungs, and show that bi-
lateral pneumothorax is not immediately fatal un-
less it is approximately total in both pleural spaces
at the same time.
Emerson regarded aspiration as responsible for
the condition in ten of forty-eight cases which he
reports, and he postulates no less than seven ways
in which this accident could occur, the commonest
of which are the probable injury to the lungs by
the needle, the creation of a negative pressure
which may cause the rupture of a superficial
cavity or an emphysematous bleb, or the tearing
of the visceral pleura at the site of adhesions.
Galliard records a case of pneumothorax due io
injury of the lung by the aspiratory needle similar
to one of Emerson’s cases. W'est asserts that he
has repeatedly obser\ ed the lung to burst under
aspiration. Such an accident becomes of serious
moment when it is recalled that it incurs not only
the danger of a sudden pneumothorax but also
the risk of infecting the pleural cavity from an
infected lung.
Symptom. vTOLOGY and Diagnosis
Forty-two of the fifty patients (84 per cent)
were males. Twenty-four (18 per cent) were in
the third decade; seventeen (34 per cent) were
in the fourth decade, and six (12 per cent) were
in the second decade, making a total of 96 per
cent in these three decades. This age incidence
will be recognized as the period in which tuber-
culosis is most active. The age incidence is as
follows :
Patients from 21 to 30 years 48%
Patients from 31 to 40 years 34%
Patients from 11 to 20 3-ears 12%
Patients from 41 to 50 3-ears 4%
Patients from 51 to 60 3-ears 2%
The right side was involved in twenty-eight pa-
tients and the left side in twenty-two.
The onset of pneumothorax may be sudden,
insidious, or silent. In seventeen cases only, the
onset was acute with stormy symptoms of
dyspnea, severe pain, cough, or shock, which is
so frequently described. In nine cases the onset
might be described as insidious in which the sjnnp-
toms were mild, gradually growing more annoy-
ing but never becoming extremely urgent. In
VoL. XII, No. 3]
Journal of Iowa State Medical Society
85
one case, it seemed likely that there were suc-
cessive accessions of air to the pleural cavity with
corresponding increase in symptoms. In twenty-
four cases the onset may be said to have been
silent, for the histories did not record symptoms
at any time that would lead to the suspicion of
pneumothorax. It is precisely this group of cases
that is overlooked unless the age incidence of the
disease and the fact that tuberculosis is the usual
etiologic factor be kept in mind and unless a care-
ful and systematic examination be made of the
chest. Seventy-five per cent of these silent cases
were revealed only by the x-ray and by operative
findings.
Pepper, in an analysis of 500 case histories,
found that the onset of pneumothorax was in-
sidious in 115 cases (23 per cent). Fredericq
has reported two cases which occurred without
symptoms. Rist and Ameuille found at necropsy
supradiaphragmatic collections of air which had
previously escaped detection. This, they assert,
is the usual site of pneumothorax in tuberculous
subjects. They believe the accident is often
terminal and accounts for the ante morten dysp-
nea. Sabourin has reported cases in tuberculous
subjects in which the pneumothorax occurred in
the fissures, remaining interlobar because of
pleural adhesions at the periphery of the lung.
These cases fall into the group in which are few
or no symptoms and he holds that amphoric
breathing along the fissural line is the sign of
greatest importance.
In the cases in our series in which the onset
was acute there was sudden pain in the chest,
dyspnea, and cough either alone or in combina-
tion. In a few cases the pain was referred below
the diaphragm. In one case the patient had for
months been able to produce a splash by shaking
the body.
In 10 per cent of the cases there was a history
of the patient suddenly raising a large quantity of
sputum, a fact that should always arouse the sus-
picion that pneumothorax may have occurred.
In interpreting physical signs it must be borne
in mind that one is likely to find fluid complicat-
ing pneumothorax. In thirty of our cases (60
per cent) fluid was present. No phase of ex-
ploration of the chest should be neglected. In-
spection may reveal cynosis, dyspnea, absence of
respiratory movement on the affected side, dis-
placement of the heart, and occasionally, a filling
out of the interspaces on that side. Cruice ob-
served bulging of the chest in 77 per cent of cases,
but in our series this was a very infrequent find-
ing except in the cases complicated by a large
amount of fluid. Percussion may not yield sig-
nificant information as the note may vary through
resonance, to tympany, and to dullness. The note
may be indistinguishable from that obtained in
emphysema or effusion. Thacher attributes the
dull note of percussion to air under tension
which robs the wall of the chest of its elasticity
and thus impairs its resonance. In our experi-
ence the most accurate percussion sign is obtained
by the determination of lung motility. In pneu-
mothorax it is found that resonance covers the
entire pleural area and is unaffected by inspira-
tory movement. In the normal lung a shifting of
resonance during expiration and inspiration is
easily discovered. If maximum inspiratory reson-
ance is maintained during both phases of respira-
tion, there is air in the pleural cavity. If, how-
ever, pneumothorax is complicated by the pres-
ence of fluid, an easily diagnosed shifting dull-
ness and succussion splash provides sufficient
data for a positive diagnosis.
On auscultation the coin test was the most con-
stant finding in our cases, and Cruise states that
it was present in 90 per cent of his cases. Dis-
tant or absent breath sounds are highly important
findings. Metallic tinkle was found in only a
few cases of the series, and amphoric breathing
was an infrequent finding. The absent or dimin-
ished excursion of the affected side, distant or ab-
sent breath sounds, the bruit d’ airain, and the
succussion splash are the signs of chief diagnostic
importance.
The method of the production of the metallic
tinkle is still a subject of controversy. Barach,
from an experimental study, concluded that me-
tallic tinkle is produced most typically by a bubble
of air escaping from the fistulous opening of a
diseased lung below or at the level of the fluid.
He asserts that it may be produced by the burst-
ing of a bubble within a bronchial tube when the
bronchial tube is connected directly with the air
chamber by a fistulous opening of sufficient size,
or by a bubble rising from the moist surface of a
perforated lung above the level of the liquid when
the bubble is expelled with sufficient force. All
of these methods presuppose a patent perforation
of the lung.
West believes that metallic tinkle may be pres-
ent in the absence of fluid and is then due to the
escape of bubbles of air from the ruptured pleura
into the distended pleural cavity. Thacher be-
lieves that rales in the neighborhood of large
cavities and particularly in pneumothorax set up
vibrations whose higher overtones are so pro-
nounced that the sounds become musical tink-
lings. Rosenbach holds a similar view. Galliard
records a case of left sided pneumothorax in
86
Journal of Iowa State Medical Society
[March, 1922
which a metallic tinkle could be heard synchron-
ous with the heart beat when the patient lay on
his back, on his left side, or was in a sitting po-
sition. Galliard ascribed this to mediate percus-
sion by the heart on the resonant space formed by
the distended pleura. We have seen this illus-
trated in a case of advanced tuberculosis with de-
struction of the entire left lung and its area oc-
cupied by a single immense cavity. A pericardiac
friction rub could be heard at a distance from the
patient as a very high pitched metallic sound. It
was accentuated if the patient’s mouth was
slightly open. We believe this to be due to the
amplifying influence of the large air chamber.
A similar difference of opinion exists concern-
ing the genesis of amphoric breathing, some au-
thorities (Thacher, Norris and Landis), claiming
that a patent opening between the lungs and
pneumothorax cavity is a necessity. Others be-
lieve it may be generated by vibrations propa-
gated from neighboring parts of the lung or bron-
chial tree (Lord, Fussell and Riesman). We are
of the opinion that both mechanisms can produce
it provided the proper tension is attained in the
wall of the chest to produce unrythmic vibrations.
Certain rare symptoms and signs of pneumo-
thorax are worthy of mention. Lublinski records
a case in which there was paralysis of the left
recurrent laryngeal nerve caused, he believes, by
the marked displacement of the heart to the right.
The paralysis disappeared when the lung reex-
panded and the heart had returned to its normal
position.
Honeij reports a case of left pneumothorax
with adhesions which prevented complete col-
lapse of the lung in which there were non-expan-
sile pulsations in the left posterior axillarj' line
from the scapula to the base caused by heart pul-
sations transmitted through the fluid. Ingram
records a case of generalized subcutaneous em-
physema, a complication of tuberculous pneumo-
thorax, which appeared first at the root of the
neck. Since there was no rent in the parieta!
pleura he believed that the rupture occurred in the
mediastinum, the air from thence making its way
along the trachea to the root of the neck.
Williamson in a study of thirteen cases of
pneumothorax and hydropneumothorax, found
that the blood-pressure on the affected side was
16.5 m.m. me"cury lower in the leg than in the
arm. He attributes this to intrapleural pressure
on the descending aorta.
An interesting, and probably not infrequent,
occurrence is the onset of pneumothorax with ab-
dominal symptoms. Beardsley reports such a
case in a patient with tuberculosis of the lungs
and bowels in which the onset was sudden with
acute pain to the left of the umbilicus, and mus-
cular rigidity which led to the suspicion that an
ulcer had perforated. At necropsy two days later
there was no perforation, but a left pneumothorax
with marked displacement of the heart was found ;
this condition had not been considered before
death.
During the influenza epidemic in 1920, we ob-
served served two cases in which empyema began
with pain and board-like muscular rigidity simu-
lating acute abdominal crisis. We believe this to
be referred pain through the seventh to the
twelfth dorsal segment. Pneumothorax was not
a complication and both patients recovered. The
effect of fluid and air on pleura however, is
identical.
Sampson, Heise and Brown have made a study
of pulmonary and pleural annular shadows ob-
served in roentgen examination of fifty patients.
These shadows were formerly interpreted as in-
trapulmonary cavities, but further studies led the
authors to conclude that the shadows occur in
patients who are probably suffering from pul-
monary softening, and they indicate a rupture of
the lung. These localized pneumothoraces usu-
ally occur in the upper part of the great oblique
fissure and in the horizontal fissure on the right ;
they may have a mural location. They frequently
contain fluid and thus present fluid level which
may be seen to shift when the patient changes
position during fluoroscopic examination. The
annular shadows surround areas of increased or
equal absorption of the ray. These authors as-
sert that such pneumothoraces can rarely be diag-
nosed clinically. They were found in 11.8 per
cent of 423 cases.
If the physician rarely primarily discovers
these shadow-like rings, he often excludes a true
cavity by clinical diagnostic methods. In one of
the cases of our series a shadow of this type was
discovered and diagnosis of pulmonary cavity
was made by the aid of the roentgen ray. Ex-
amination of the chest in the region of the ring
revealed that whispered pectoriloquy, cavernous
or amphoric breathing, gurgling or consonating
rales were absent. Over this area percussion
yielded a tympanitic note and pleuritic friction
sounds were heard which, taken with the fact
that the ring occurred over the right lower lobe,
made the diagnosis of intrapulmonary cavity un-
tenable.
Fishberg, in an earlier article, called attention to
these localized pneumothoraces. In differentiat-
ing them from pulmonary abscess he points out
that in the latter moist consonating rales, broncho-
VoL. XII, No. 3]
Journal of Iowa State Medical, Society
87
plaony and an absence of metallic tinkle or am-
phoric breathing may be noted. In the former,
he emphasizes the sudden onset, the absence of
adventitious sounds, the presence of metallic tin-
kle, amphoric breathing and whispered pectorilo-
quy. These signs are most suggestive when heard
high in the axilla.
False pneumothoraces, which may be defined
as extrathoracic collections of air, must be ex-
cluded. Lebon, in a roentgenologic study of these
cases, found that the stomach, distended with
gas, projected far into the left side. In one case
the heart was displaced to the right, and in one
an air bubble in the stomach lay between the left
margin of the heart and the wall of the chest.
Stivelman asserts that hydropneumothorax may
be simulated by cases in which the diaphragm is
in a high position due either to extreme pul-
monary fibrosis or gastrectases, and that these
extrapleural pouches are characterized by their
failure to absorb the contained gas, the fluid level
varying with food ingestion and the emptying of
the stomach. On fluoroscopic examination a ba-
rium bolus may be seen to enter the supposed hy-
dropneumothorax. Thus the roentgen ray is an
indispensable adjunct in the diagnosis of pneumo-
thorax, especially in the localized and the so-
called false varieties.
Prognosis
The prognosis of pneumothorax is largely the
prognosis of the pulmonary lesion which it com-
plicates. If it occurs in tuberculous subjects, the
outcome will depend largely on the degree of in-
volvement of the lung by the tuberculous process.
In a few cases pneumothorax results from the
rupture of a solitary nodule of the lung with no
discoverable pulmonary lesions elsewhere, as in
the cases cited by Weber. These cases obviously
offer a more hopeful prognosis than those in
which extensive and rapidly advancing disease of
the lung is a complication. Pneumothorax occurs
chiefly in the rapidly advancing type of pulmon-
ary tuberculosis or in the terminal stages of the
disease and hence is regarded as a grave prog-
nostic sign.
In the analysis of fifty-one cases of pneumo-
thorax in tuberculous subjects, Morse states that
the pneumothorax is the cause of death in 60 per
cent, that 80 per cent of the patients die in less
than one year, and that 10 per cent live more than
five years. West in an analysis of 101 cases of
tuberculous pneumothorax states that the mor-
tality was 65.4 per cent. In thirty-nine of these
patients the duration of life was known; 75 per
cent died within the first fortnight and 90 per
cent within a month. The presence of annular
shadows indicated a somewhat graver prognosis
in the series of cases studied by Sampson, Heise
and Brown. In all cases the prognosis further
depends on the rationality of the treatment
adopted both with respect to the general suppor-
tive measures, and to the operative treatment em-
ployed in combating urgent dyspnoea, and in the
management of collections of fluid, or pus in the
chest.
Fussell and Riesman collected from the lit-
erature in 1902 fifty-six cases in which there
was but a single death from spontaneous pneu-
mothorax. In five of our cases classified as
spontaneous there were no deaths. However, in
a later case not included in the series, the patient
was seized with symptoms of urgent dyspnoea
following an operation for extirpation of the
lacrymal sac, and death followed in five hours un-
der expectant treatment. A previous careful ex-
amination had not revealed evidence of pulmon-
ary disease and the case was classified as spon-
taneous pneumothorax. As a whole, the patients
with spontaneous pneumothorax have the best
outlook, provided they weather the storm of the
sudden onset.
Six deaths are known to have occurred in our
series of fifty patients, one from influenza, one
from abscess of the lung, and four from the
combined effects of advanced tuberculosis and
empyema. It has not been possible to obtain
data concerning the remaining patients long
enough to make our mortality statistics of value.
Treatment
The part which Emerson believes aspirations
play in his cases has been pointed out herein.
Previous to entering the Clinic, nineteen of our
patients were aspirated on an average of 2.8
times. No doubt pneumothorax and what is per-
haps its most serious complication, infection of
the pleural cavity, might be avoided in many in-
stances if aspirations were practiced less fre-
quently or if they were performed by men more
experienced in surgical technic. Only the most
careful technic is permissible in these cases. We
believe that expectant treatment is insufficient
in the urgent cases. Paracentesis should be tried ;
this view is supported by Fussell and Riesman,
Meyer, Lord, Rosenbach, Finlay and Weber.
Lord, and especially Rosenbach prefer to give
conservative methods a thorough trial first. West
considers aspiration dangerous, and uses a fine
trocar or needle to which he attaches a rubber
tube, the latter being allowed to open under sterile
water. This method commends itself as the one
calculated to do the least injury. In referring to
the danger of reopening the perforation, Finlay
88
Journal of Iowa State Medical Society
[March, 1922
aptly remarked. “It is better to run the risk
than to allow the patient to die from asphyxia-.’’
Marshak and Craighead report six cases of sud-
den pneumothorax occurring during the course
of induced pneumothorax. Their patients were
successfully treated by repeated aspirations con-
trolled by manometric readings. Sufficient air
was withdrawn to relieve the dyspnoea but
not enough to allow the lung to reexpand. The
method is certainly logical but requires a special
apparatus and some skill in its use. Finally, a
great many patients under expectant treatment
promptly adjust themselves to the new circulatory
and respiratory conditions. However, it is prob-
ably better to perform a paracentesis a little too
early than to delay too long.
We consider that aspiration in hydropneumo-
thorax is indicated only for diagnostic purposes
or to relieve urgent dyspnoea. The most serious
danger of repeated aspiration, aside from that
creating a superadded pneumothorax, is the dan-
ger of converting a hydropneumothorax into a
pyopneumothorax, a sequence that had occurred
in five of our tuberculous patients before we saw
them. Rosenbach, in speaking of paracentesis, in
such cases says, “If the exudate is at all large
two or three repetitions of the procedure, even
when carried out with the greatest care, are
practically certain to produce putrefaction and
lead to rapid loss of strength.”
The treatment of pyopneumothorax follows the
principles of the treatment of ordinary pyothorax
except the taking into account of the underlying
lesion of the former which is frequently tuber-
culosis complicated by a pyogenic infection, a
condition peculiarly refractive to ordinary meth-
ods of treatment and one warranting a ver}
guarded prognosis.
All writers agree that pneumothorax as a ther-
apeutic measure in tuberculosis is indicated in re-
peated haemoptysis. Robinson and Floyd advo-
cate its use in cases advancing in spite of the
usual methods of treatment. INIorris, among other
indications, advised the use of the method in re-
cent progressive ulcerative lesions with slight ac-
tivity in the opposite lung. The measure was em-
ployed for two of our patients, one was given
twenty injections, over a period of seven months.
hydropneumothorax and a greatly thickened
pleura resulted. Another patient having had a
number of air injections developed a series of
sinuses at the site of injections, and a pyopneumo-
thorax. These results do not necessarily con-
demn the method, but point out possible danger-
ous sequelae. We agree with Kendall and Alex-
ander that pleural effusions, especially if they
are purulent are serious complications. They are
believed to occur as a complication of artificial
pneumothorax in from 20 per cent (Kendall and
Alexander) to 50 per cent of cases. Simon and
SWezey have reported a case of lung abscess suc-
cessfully treated by two injections of air into the
pleural space. One of our patients had been treated
in this manner for four months and presented him-
self with a pneumothorax and an abscess of the
lung. His chest was aspirated five times, rib resec-
tion was performed twice ; the patient finally died
from pulmonary hemorrhages. It is question-
able whether one should temporize with such a
method for it seems inadequate in dealing with
such a serious disease. Although the procedure
will not induce the cure for pulmonary diseases
that may have been expected, yet we believe with
carefully selected cases, and careful examina-
tions, artificial pneumothorax has won its place
as a worthy therapeutic procedure.
BIBLIOGRAPHY
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7. Cloetta, M.: Ueber die Zirkulation in der Lunge und
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VoL. XII, No. 31
Journal of Iowa State Medical Society
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23. Hewlett, A. W. : The clinical features of spontaneous
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tions gazeuses qui se forment dans la poitrine. These, Paris,
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27. Laennec, R. T. H. : A treatise on the diseases of the
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28. Laennec, R. T. H. : Quoted by Emerson.
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tusion de la paroi thoracique. Lyon Med., 1914, cxxii, 15-17.
31. Letulle, M.; La tuberculose pleuro-pulmonaire. Paris,
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32. Lockwood, A. L. : Personal communication.
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Crae, T. ; Modern medicine. Philadelphia, Lea and Febiger,
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klin. Wchnschr., 1906, xliii, 18.
35. McLeod, J. J. R. : Physiology and biochemistry in mod-
ern medicine. St. Louis. C. V. Mosby Co., 1920, 3 ed., pp.
321-323.
36. Marshak, M. I. and Craighead, J. W. : A case of recur-
rent pneumothorax. Am. Rev., Tuberc., 1917, i. 109-113.
37. Means, J. H. and Balboni, G. M. ; The various factors of
respiration in persons with pneumothorax. Jour. Exper. Med.,
1916, xxiv, 671-681.
38. Meyer, A. : A case of bilateral, spontaneous nontuber-
culous pneumothorax with autopsy. New York Med. Jour., 1917,
cv, 1238-1242.
39. Morris, E- : Induced pneumothorax. Its use in the treat-
ment of pulmonary tuberculosis, with a report of 202 cases. Am.
Rev. Tuberc., 1918-1919, ii, 485-496.
40. Morse, J. L.: An analysis of fifty-one cases of pneumo-
thorax. Am. Jour. Med. Sc., 1900, cxix, 503-509.
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Assn., 1898, xxxi, 151-165; 208-216; 281-297; 341-356.
42. Norris, G. W. and Landis. H. R. M. : Diseases of the
chest and the principles of physical diagnosis. Philadelphia,
Saunders, 1920, 2 ed., 844 pp.
43. Pepper, O. H. P. : The insidious onset of pneumothorax.
Am. Jour. Med. Sc., 1911, cxlii, 522-530.
44. Rist, E. : -Artificial pneumothorax. Quart. Jour. Med.,
1912-1913, vi. 259-290.
45. Rist, E. and Ameuille, P. : Le decouverte a I’autopsie du
pneumothorax latent de la base. Bull, et mem. Soc. med. d. hop.
de Par., 1920, xliv, 99-102.
46. Robinson. S. and Floyd, C. : Artificial pneumothorax as
a treatment of pulmonary tuberculosis. Arch. Int. Med., 1912,
ix, 452-483.
47. Rosenbach, O.: Pneumothorax: In Nothnagel’s en-
cyclopedia of practical medicine. Philadelphia, Saunders, 1902,
iv, 972-1013.
48. Sabourin, C. ; Sur le pneumothorax scissural. Arch. gen.
de med., 1905, i, 1089-1096.
49. Sampson, H. L., Heise, F. H. and Brown, L.: A study of
pulmonary and pleural annular radiographic shadows. Am. Rev.
Tuberc., 1918-1919, ii. 664-689.
50. Thacher, H. C. : In Flint, A. : Manual of physical diag-
nosis. Philadelphia, Lea and Febiger, 1920, 8 ed., 362 pp.
51. Simon, S. and Swezey, S.: An acute pulmonary abscess
treated by artificial pneumothorax. Am. Rev. Tuberc., 1918-1919,
ii, 92-95.
52. Stivelman, B. P. : False pneumothorax. Jour. Am. Med.
Assn., 1920, Ixxiv, 12-14.
53. Tuffier, T. : L’ouverture de la plevra sans pneumo-
thorax. Presse med., 1906, xiv, 57-60.
54. Weber, F. P. ; Pneumothorax in tuberculous subjects.
Lancet, 1905, ii, 813-817.
55. Weiss, A. : Ueber Komplicationen bei der Behandlung
mit kunstlichem Pneumothorax. Beitr. z. klin. d. Tuberk., 1912,
xxiv. Heft 3, 333-365.
56. West, S. : Quoted by Fussell and Riesman.
57. West, S.: A contribution to the pathology of pneumo-
thorax. Lancet, 1884, i. 791-793.
58. West, S.: On paracentesis and the use of the aspirator
in pneumothorax. Lancet, 1904, i. 751-752.
59. West, S. : Bedside clinics. Clinical Jour., 1905, xxvii,
129-130.
60. West. S. : Intrapleural tension. In: -Allbutt, C. and
Rolleston, H. D. : -A system of medicine. London, Macmillan,
1909, v. 519-531.
61. West, S. : Quoted by Osier, W. and McCrae, T. : The
principles and practice of medicine. New York, Appleton, 1920,
9 ed., 1168 pp.
62. Williamson, O. K. : -A new physical sign in pneumothorax
and in pleural effusion. Lancet, 1917, ii, 13-14.
63. Zahn, F. W.: Ueber die Entstehhungsweise von Pneumo-
thorax durch continuitatstrennung der Lungenpleura ohne eitrige
Entzundung. -Arch. f. path. Anat., 1891, cxxiii, 197-220.
THE ACUTE ABDOMEN*
Edward F. Beeh, M.D., Fort Dodge
The acute abdomen is either medical or surgi-
cal, and whenever a case presents itself with
acute symptoms referable to the abdomen, we
should always look upon it as an emergency until
absolutely proven otherwise. We should use ev-
ery means at our command to arrive quickly at a
correct diagnosis, for every moment lost will di-
minish the chance of recovery if an emergency
exists.
If after the diagnosis, the abdomen is medical,
the management of the case and the plan of treat-
ment can be worked up and thought out at the
discretion of the attendant, but if the abdomen is
surgical the treatment is that of an emergency.
In the treatment of the acute surgical abdomen,
cathartics have no place, the most which can be
accomplished by their use, in any case, is to dem-
onstrate that the condition is not serious. In ev-
ery case in which the use of a cathartic is not ac-
tually dangerous to the life of the patient, it is not
needed, because there will be a natural evacuation
if no remedy is used. ‘Never in any acute inflam-
matory condition of the abdomen use a cathartic
and especially is this true in any form of obstruc-
tion, whether this be due to strangulated hernia,
bands or adhesions, intussusception, kinking of
intestines, diverticulae, volvulus or neoplasms, for
any one of these, the intestine suffers so severely
as a result of the pressure from the peristalic ac-
tion caused by cathartics that the walls become
permeable to the passage of septic material, and
thus scatter it throughout the abdomen. There
can, therefore, be no reason why peristalsis should
be initiated by the use of cathartics. Even the
smallest amount of cathartic may change a harm-
less circumscribed infection into a serious diffuse
peritonitis, and in the non-obstructive cases the
empty bowel is not desirable, because it is indu-
cive to gas.
Morphine also, is a most dangerous drug in the
treatment of acute abdominal disease, and is a
foe to accurate diagnosis, since it inhibits peris-
‘Presented before the Seventieth Annual Session Iowa State
Medical Society, Des Moines, Iowa, May 11, 12, 13, 1921.
90
Journal of Iowa State Medical Society
[March, 1922
talsis and favors relaxation of the abdominal wall
in those peritoneal lesions, where rigidity is one
of the best clinical signs. IMorphine should only
be given, when it has already been decided to
operate, or where it is certain that operative inter-
ference will not be required.
The treatment of the acute surgical abdomen,
is operative, in the language of the great Murphy,
“Now is the acceptable time,” meaning that as
soon as the diagnosis is made, operation is in or-
der. Murphy spoke thus of appendicitis, but let
us take a stride farther and say that in the acute
surgical abdomen, now is the acceptable time to
operate. The judgment of the majority of sur-
geons, is that immediate operation at whatever
time, the condition is recognized is not only justi-
fiable but will conserve tht best interests of the
patient.
Taking this as our cue let us go over the acute
surgical abdominal conditions taking what we
need of the history, symptomology, physical and
laboratory findings necessary for a diagnosis, and
what surgery is necessary for the best interest of
the patient. We will at this time, for the reason
of conserving time, omit the acute pelvic condi-
tions which in reality are not the truly abdominal
conditions but rather pelvic and come under the
jurisdiction of the obstetrician and g^mecologist.
Also we will omit the extra peritoneal conditions.
For some time it has been generally accepted
that in many cases of disease in the abdomen, a
pathological tripod stands in that cavity with feet
implanted in the appendix, biliary apparatus, and
eastro-duodenal tract. The co-existence and se-
o
quential development in any order of appendicitis,
cholecystitis, or cholangitis, and gastric or du-
odenal ulcer, is familiar to clinicians and sur-
geons. Opinions vary as to whether one or the
other of the three stands in casual relation to the
others, or all three are derived from a common
and central source, in the form of catarrhal in-
flammation of stomach and bowel.
As the records of cases accumulate, it is be-
coming evident that the tripod is being gradually
replaced in the problem, by a quadrupedal figure
— -pancreatitis is claiming increasing attention.
Acute Pancreatitis
Acute pancreatitis, necrotic, hemorrhagic and
suppurative is rarely suspected until discovered at
autopsy, or in the course of a laparotomy under-
taken for a supposed perforated gastric or duod-
enal ulcer, a fulminating appendicitis, or other
similar acute abdominal affection calling for
operation. The case commonly goes to the oper-
ating table a surgical puzzle and leaves the hos-
pital by way of the morgue a surgical disaster,
though operative treatment is now claiming an
increasing number of successful results.
A condition that more closely resembles a per-
forating hollow viscus is acute pancreatitis, the
pain is perhaps more severe than in any of the
other abdominal condition with the exception
perhaps, of perforated ulcer, and rupture of the
gall bladder; in fact, it is often so overwhelming
as to cause early collapse and syncope. I once
heard Dr. J. B. Murphy say that this is the only
pain not relieved by a one-fourth grain morphine
given hypodermically. It is often the collapse
and extreme pallor upon which the diagnosis of
the condition is made. The pain may be either
constant or paroxysmal with a tendency to local-
ize in the epigastrium, but it may radiate to the
left. Rigidity is not extreme, but tenderness in
either the epigastrium or left costovertebral angle
depends upon whether the body or the tail is the
site of the pancreatic lesion. Vomiting is persist-
ent, and constipation often so obstinate as to sug-
gest intestinal obstruction, a diagnosis that is in-
frequently made. Distention is a marked symp-
tom, at first appearing in the upper abdomen, but
later becoming generalized. The pulse is char-
acteristically small and weak. The temperature
is not very significant, although in very acute
cases it may be subnormal, while in the subacute
it may rise to 103° or 104° F., glycosuria sets in
later as tissue destruction advances.
The fact that the symptoms of acute pancre-
atitis are preeminently those of peritonitis makes
diagnosis difficult, yet any abdominal condition
ushered in with severe, agonizing pain, with
symptoms of peritonitis should be looked upon as
pancreatitis. The treatment is surgical and should
be instituted at once.
Acute Appendicitis
The symptoms of this acute abdominal condi-
tion in the order of their occurrence, may be
mentioned as ; first, pain in the abdomen, sudden
and severe, primarily referred to the epigastrium,
usually colicky in character, although patients
vary in their expresions of its severity. Never is
it absent as an initial symptom and reaches its
acme of intensity about four hours after its onset
and subsides gradually in the majority of cases,
when it ceases suddenly within the first thirty-six
hours, the subsidence is due either to the libera-
tion of the infective material into the cecum-
rupture, or complete gangrene. The secondary
pain, after the first thirty-six hours in usually not
colicky, but of the typical inflammatory type, and
due to periappendicular involvement. Severe
VoL. XII, No. 3]
Journal of Iowa State Medical Society
91
pain after the primary subsidence is always a sig-
nal of great danger, as it announces a beginning
peritonitis from perforation.
Second ; nausea or vomiting, most commonly
between three and four hours after the onset of
pain, it is reflex, due to overdistension of the ap-
pendix from the accumulating products of the in-
fection. There are usually only a few efforts at
emesis and the nausea then passes away. The
secondary nausea, and often persistent vomiting,
are due to the periappendicular involvement, that
is, infection of the peritoneum.
Third; general abdominal sensitiveness, most
marked on the right side or more particularly
rigid. When the appendix becomes fully dis-
tended and tense, it will not tolerate pressure and
is protected by a marked rigidity of the ab-
dominal muscles. After the acute tension sub-
sides, the sensitive area becomes circumscribed in
the region of the appendix.
Fourth; elevation of temperature beginning
from two to twenty-four hours after the onset of
pain. It is never absent in the acute infective
case in its early stage ; that is, in the first thirty-
six hours after the onset of the symptoms.
Fifth; leucocytosis which is to be considered
only as corroborative, should be sought as a mat-
ter of routine. Where the absolute white count
is 20,000 or over, there is reason to suspect the
presence of pus.
The treatment is operative, procrastination
should not be regarded as a manifestation of
knowledge, experience, judgment, or true con-
servatism.
Gall Bl.adder Disease
Next to appendicitis, gall bladder disease is
probably the commonest intra-abdominal lesion.
This is evident both by the reports of operative
procedure and by necropsy statistics. Most writ-
ers on glall bladder disease have noted the great
preponderance of the disease in the female sex as
contrasted with the male. It is essentially a dis-
ease of middle age, but undoubtedly many lesions
originate early in life but remain dormant, or pro-
duce indefinite, minor or vague symptoms until
middle age. It occurs with increasing incidence
with the advancing decades, the greatest fre-
quency being between forty and fifty years of
age. In affections of the gall bladder, reliance
must be placed upon a history of repeated attacks
of gall bladder pain. Patients presenting them-
selves with gall bladder trouble may be divided
into one of three groups.
Group 1. Typical Biliary Group — These cases
are characterized by severe pain, usually local-
ized in the epigastrium or right hypochondrium.
sudden in onset, and in cessation, radiating usu-
ally to the back and shoulder, frequently accom-
panied by nausea and vomiting, and requiring
morphine for relief. Recurrent attacks, usually
extending over a long period of time, of increas-
ing frequency, and associated occasionally with
transient jaundice.
Group 2. Atypical Biliary Group- — In this
class of patients the symptoms are mainly dull
aching pain in the upper right quadrant with ten-
derness, fever, some nausea and vomiting. The
pain is usually of several days’ duration. Jaund-
ice may or may not be present. The attacks are
fairly typically inflammatory in character and in
findings, are usually accompanied by a septic tem-
perature curve, and a fairly high white blood
count.
Group 3. Gastric Group — Patients of this
group have attacks characterized by epigastric
distress or discomfort, a feeling of fullness after
meals, relieved by belching of gas and sometimes
by vomiting. Idiosyncrasies for various kinds of
food are quite prominent, giving the so-called
“qualitative” food dypepsia in contrast to the
quantitive food dypepsia of gastric ulcer. Many
of these patients are treated for years for gastric
or duodenal ulcer without any special- permanent
relief.
The treatment is operative and cholecystectomy
is the operation of choice in cholecystitis and
cholelithiasis whenever feasible. There is marked
beneficial effect in the long continued drainage
of the biliary passages in the complicated cases
of cholecystitis and pancreatitis. There is an in-
creasing mortality rate with the increase in the
complication of disease, hence the argument for
early diagnosis and operation.
Perforated Gastric and Duodenal Ulcer
The subject of diagnosis has been so thoroughly
worked out, that there is little to say respecting
gastric and duodenal ulcer. The history, when
carefully taken in duodenal ulcer, is so typical
with respect to periodicity, the attacks occurring
usually in the autumn and spring, premeal pain,
pain particularly at midnight, and vomiting at the
same midnight hour if at all, coupled with the
finding of blood in the stomach contents or in the
feces, this depending upon the time of examina-
tion and the age of the ulcer. Occasionally, in
both the duodenal and gastric ulcers, the perfora-
tion occurs without any previous symptoms, but
usually a definite ulcer history can be elicited pre-
vious to the symptoms of perforation. The pa-
tient suffers from a very acute pain in the upper
portion of the abdomen, and the pain is usually
92
Journal of Iowa State Medical Society
[March, 1922
described as coming on with a feeling as though
something had ruptured. The pain is sudden,
violent and agonizing and may be referred to the
chest, the back or the shoulders.
There is early nausea and usually vomiting of
stomach contents, which may or may not be
mixed with blood. Physical examination elicits
a rigidity which is first marked in the upper ab-
dominal zone, and is extreme and board like, and
more severe than in any other pathological con-
dition in the belly.
Immediate operation is always indicated pro-
viding the jiatient comes under observation dur-
ing the fir.st twelve hours, after this, the method
of treatment must depend upon the judgment of
the surgeon. The rupture must be repaired using
care not to cause a narrowing which might later
produce an obstruction. Thorough drainage
should be established, and while it is the con-
census of opinion that it should be a routine to
perform a gastroenterostomy at the time of clos-
ing, yet others state that it is rarely necessary or
wise to do so.
Inte-stinal Obstruction
Patients suffering from intestinal obstruction,
whatever the cause, should be operated at once
and they should never, under any circumstances,
receive either cathartics or food by mouth after
this condition is even suspected. This condition
demands not only judgment and technical skill,
but also experience for its best treatment. Time
must not be lost, operation should not be reserved
as a last resort, it is the conservative treatment
and should be applied at once.
Mistakes of diagnosis are not so serious as de-
lay of operation, the conditions which may be
mistaken for acute intestinal obstruction are also
conditions requiring operative treatment. The
diagnosis should not be difficult, there is consti-
pation, pain in the abdomen, and vomiting. Pain
sets in early, and may come on abruptly w'hile the
patient is walking, or more commonly during the
performance of some action. It is at first colicky
in character, but subsequently it becomes contin-
uous and very intense. Vomiting follows quickly,
and is a constant and most distressing symptom.
At first, the contents of the stomach are voided,
and then greenish bile stained material and soon,
in cases of permanent obstruction, the material
vomited is a brownish-black liquid, with a dis-
tinctly foecal odor. This sequence of gastric,
bilious, and finally intestinal vomiting is perhaps
the most important diagnostic feature of acute
obstruction. When the obstruction is low down,
especially in the colon, vomiting may not come on
for many days, even though the obstruction is
complete. “The higher the trouble the sooner the
vomiting, is a good general rule.”
Congenital Pyloric Stenosis
As to the characteristic symptoms and clinical
findings, it will be noticed first, that the patient
has only slight vomiting at the age of fourteen to
twenty-one days. The onset may occur from two
to six weeks of age, rarely in the first, most often
in the second or third. The vomiting gradually
increases in severity until it becomes projectile in
character. There will be constipation to a certain
degree with green mucus stools, the constipation
develops in proportion to the degree of obstruc-
tion. On examining the abdomen one can readily
see the peristaltic waves passing from the left
hypochondric region. The diagnosis is based
primarily on these peristaltic waves, projectile
vomiting and progressive loss of weight. In-
fants with well developed pyloric stenosis not
only show extreme emaciation and starvation, but
there is extreme dehydration with the passage ot
very small amounts of urine. Secondarily the
diagnosis is based upon palpation of tumor, the
finding of which depends upon: 1. Behavior of
babe during examination. 2. Emaciation. 3.
Location of tumor in relation to adjacent viscera,
and fluoroscopic examination, and I should put
fluroscopic evidence to the last and least, since it
only visualizes information previously obtained.
Early diagnosis and early operation gives the
best chances for recovery. The operation of
choice is the Ramstedt or some modification.
Intussusception
The suddenness of the onset is quite character-
istic of intussusception, the majority of cases are
ushered in with sudden, violent pain of colicky
character, which is followed shortly by vomiting,
then a diai'rhea first of fecal matter, then mucus,
bloody mucus, or pure blood, together with their
liquid bowel contents. At this time there are
symptoms of marked prostration and even col-
lapse. The pulse becomes small and rapid, and a
rise in temperature in the early stages is rarely
observed. Tenesmus and meteorism is fre-
quently a source of great suffering. If the child
is given freedom on the bed, it will take the knee
chest position, burrowing the head into the pillow
during the course of the pain.
The treatment is operative, and requires a great
deal of surgical judgment on account of the vary-
ing amounts of pathology and damage produced
by the intussusception. The treatment will
vary from simple reduction, to resection and
anastomosis.
VoL. XII, No. 3]
Journal of Iowa State Medical Society
93
Perforating Typhoid Ulcers
Early diaguo.sis and early operation mean the
saving of one-third of the cases of this hereto-
fore uniformly fatal complication of typhoid
fever. The aim should be to operate for the per-
foration, and not wait until a general peritonitis
diminishes by one-half the chances of recovery.
An incessant, intelligent watchfulness on the part
of the medical attendant and the early coopera-
tion of the surgeon are essentials. Every case of
more than ordinary severity should be watched
with special reference to this complication. Thor-
ough preparation by early observation, careful
notes of the progress of the case, and a knowl-
edge of the present condition will help to prevent
needless exploration. No case is too desperate,
and in doubtful cases it is best to operate as ex-
perience shows that patients stand an exploration
very well. Perforation occurs usually between
the fourteenth and twenty-first days, or in other
words, in the third week of the disease, the loca-
tion of which is mostly in the last twelve inches
of the ileum. Sudden, severe, agonizing pain,
with extreme tenderness and rigidity, being the
cardinal signs of perforation. The lesion is best
exposed at the site of greatest tenderness.
Perforations and Traumatic Injuries
Every abdominal wall which shows a penetrat-
ing sound, whatever its location and whatever the
agent that inflicted the wound, should be opened.
Similarly, severe blows on the abdomen, or a fall
on the abdomen, or being crushed between wheels
etc., should bring- to mind the possibility of one
of the various subacute injuries that not infre-
quently occur. In these cases it is better to open
the abdomen on suspicion and find nothing, than
to wait for an assured diagnosis and hemorrhage.
Omentum
The disease of the omentum that comes under
this category is torsion, and torsion of the omen-
tum may occur in a hernial sac, or within the ab-
dominal cavity. Inside the sac of a hernia, tor-
sion of the omentum is not uncommon, and the
symptoms it produces are those of some degree
of strangulation, associated with the presence of
an irreducible hernia, in some cases the origin of
the twist may be attributed to the existence of a
hernial sac, but the omentum may be withdrawn
into the abdominal cavity and yet the symptoms
persist. Concerning torsion, apart from the pres-
ence of a hernial sac no satisfactory explanation
can be given, but it is to be observed that in ail
the cases reported, the tumor was in the right
half of the abdomen. The symptoms are very
variable, and pain is the only one which is con-
stantly present. Vomiting and constipation may
be observed, but there may be diarrhea.
In some cases the clinical picture has been that
of obstruction, with considerable abdominal dis-
tension due to reflex paralysis of the intestine.
Temperature and pulse rate are usually above
normal. There are no physical signs which are
at all characteristic of this lesion, but in cases
where the history points to hernial trouble, and
an empty sac is associated with the presence of an
abdominal tumor on the same side as the hernia,
suspicion of twisted omentum may be aroused. In
the case of torsion associated with a hernial sac,
the natural course of operation will be to explore
the hernia first, and the twisted omentum may be
drawn down through the sac. In instances of
abdominal torsion coeliotomy is indicated, and
all that is necessary is simple ligature and exci-
sion of the involved omentum.
Spleen
Of all the contents of the peritoneal cavity, the
spleen is certainly the least liable to be at fault in
what are sometimes called abdominal catastro-
phies, if we exclude cases of injury. We must,
however, give consideration to pathological pro-
cesses to which this organ is liable, and which
may give rise to urgent abdominal symptoms.
Such lesions are usually due to haemic infections
or to anomalies of the anatomy of the spleen. The
relationship of the spleen to bacterial infection,
such as infective endocarditis, septico-pysemia,
and septic fevers, is an unknown quantity. It is
well known that this organ affords a resting place
for micro-organisms in many infections, but
whether this is to the advantage of the patient or
not, is uncertain, and the results of experimental
splenectomy have as yet failed to afford definite
information on the question.
It is important therefore, for us, and for the
public in general, to become familiar with the
danger of giving any kind of nourishment what-
soever, or cathartics by mouth in the presence of
impending peritonitis from any cause — and peri-
tonitis is impending in all acute abdominal surgi-
cal conditions. Opium nor any of its derivatives
should ever be given before a diagnosis has been
made, and a plan of treatment decided upon.
Nature — the wonderful mother has come to
our help — all of the physiological forces become
active in this assistance ; with.
Pain we have the warning signal, the cry of
distress that something has gone wrong — then
why turn a deaf ear by giving opium to cover it.
Nausea — the signal that food is not desirable —
94
Journal of Iowa State Medical Society
[March, 1922
then why attempt putting nourishment into a re-
bellious stomach.
Rigidity — the muscle spasm forming an an-
terior abdominal splint — then why use violent
manipulation which only increases the danger of
diffusion of septic material.
Distention — the colon becomes filled with gas
and acts as a coffer-dam, the small intestines
from an embankment about the diseased area (if
not disturbed by cathartics).
EveiA'thing is as favorable as can be for the
process of repair, which consists in the concentra-
tion of the activity of millions of leucocytes in
the infected area and the production of anti-
bodies in the blood, and the limitation of nutrition
of the septic micro-organism to an area in which
they will soon become reduced in virulence.
Therefore, in conclusion let me say, that the
earlier the acute abdomen is seen, and the earlier
suitable surgical treatment is instituted, the more
favorable will be the prognosis. While a correct
preoperative diagnosis is important and desirable,
in order to allow of the best preoperative prepar-
ation and the most advantageous incision, and
also, from the viewpoint of prognosis, to say
nothing of the personal satisfaction to the diag-
nostician, failure to hit upon the right cause of
the acute abdomen is not serious compared with
the seriousness of missing the most auspicious
moment for intervention. This represents one
of the greatest dangers in the acute surgical ab-
domen.
REFERENCES
Chicago Surgical Clinics.
Journal American Medical Association.
Surgerj- Gynecology and Obstetrics.
British Journal of Surgery.
Ochsness Surgery.
Warbasse Surgical Treatment.
Keenes Surgery.
Oxford Surgery.
Discussion
Dr. Charles H. Magee, Burlington — The two rec-
ommendations against the use of cathartics and mor-
phin in these cases are particularly pertinent and
cannot be repeated too often or emphasized too
much. Seven out of ten men will resort to morphin
and cathartics before the diagnosis is made. I com-
mend the essayist for bringing these points before us
again. Operate at once; very true. In this patho-
logical figure given us, I would change it a little.
I would bring in appendicitis, cholangitis, perfor-
ated ulcer, and perforated tube, leaving out the pan-
creas. He has made an attempt, and a very nice one,
too, to chart the abdomen. When we come to an
acute abdomen it is like getting out to sea, or in the
desert of Sahara, and we need landmarks. Taking
up, then, appendicitis, we remember the classical
symptoms as laid down by Murphy in appendicitis
and in cholangitis, and in perforation of the stomach
much the same. As to perforated tube, the first con-
sideration in making diagnosis of this condition
would be the specific history, and it would be this
particular historj- of a woman married rather late in
life, or a woman that has not had a labor for eight,
ten or fifteen years, and then having some of the
symptoms of pregnancy, when we would probably
diagnose the condition as extra-uterine or tubal
pregnancy. That brings us through to intestinal ob-
struction, in which condition we sometimes have a
few additional landmarks. If we operate for ap-
pendicitis and simply drain, and ileus comes on after-
wards, then we know where to go. If a man has
hernia, that gives us a hint; also a tumor, if we can
feel it, gives us a hint again. I do not know how
others get along with intestinal obstruction, but to
me the mortality is appalling. And I feel that I must
say to these men here that if I save two patients or
even one patient out of ten, I think I am doing well.
Only a short time ago I operated on a patient who
had been filled with cathartics and morphin. I just
simply helped him in making an exit, that is all. My
experience in seeing this case too late for operation
to be of avail, is the reason I expressed commenda-
tion of the recommendations made by Dr. Beeh. In
regard to the treatment of intestinal obstruction, we
have a great many theories, but I do not believe we
depart one iota from the dictum laid down by Dr.
F. Treves many years ago: To “relieve the obstruc-
tion and empty the proximal bowel.” I believe I am
correct in saying that relief of the proximal bowel is
the thing to do. If there is very much distention of
the bowel I should do an enterostomy. As Morris
says, get in quick, make the artificial anus, and get
out quicker. If there is peristalsis I make no at-
tempt to empty the proximal bowel at the time, for
if you have peristalsis the bowel will empty itself, if
peristalsis is not present the patient will die. So
there you are I believe that man}" a man has been
killed by a physician or surgeon dallying over his
belly to try to find the obstruction. I stand guilty
of three or four such cases. Perhaps I will learn in
the course of time and following further experience
along this line, but I do not know.
Dr. Thomas Byrnes, Woodward — The essayist has
given us a very commendable interpretation of the
acute surgical abdomen. Were these expressions
firmly fixed in the minds of the high school surgeon
and many in general practice as well, I am sure that
the mortality which ranks second only to the hemo-
lytic therapeutics as practiced in our recent past epi-
demic would be very much modified by the early
recognition of this acute condition. It is my opinion
that pain is the predominating factor in the estima-
tion of the acute surgical abdomen. Pain is caused
by the stimulation of cells in the pain column of the
posterior horn of the cord by either somatic or
splanchnic fibers. Then in our interpretation of ab-
dominal pain we must trace afferent stimuli along
the somatic sensory nerves and along the splanchnic
sensory nerves. Pain in peritonitis is due to a stim-
ulation of the somatic sensory fibers from the extra-
VoL. XII, No. 3]
Journal of Iowa State Medical Society
95
peritoneal fat. Visceral pain is due to deep sensi-
bility impulses from hypertonic involuntary muscu-
lature being transmitted to the same second relay
cells as the somatic afferents. Internal pressure or
tension is the result of this muscular contraction and
not the exciting cause of the pain. The skin and
extraperitoneal fat sensory nerves are reflexly con-
nected with the abdominal muscles. When stim-
ulated in peritonitis by exudate or stretching of the
parietal peritoneum, the extra-peritoneal nerves
cause reflex rigidity of these abdominal muscles,
the response of which may be localized and specific
according to the site of stimulation. The gut wall is
connected by sympathetic afferents to efferent sym-
pathetic cells, which excite inhibition of the gut-wall.
Contraction of the ureter is brought about by similar
reflex. Pain occurs when the hypertonicity of the
muscle is so great that impulses can be transmitted
by the pain path to the cortex. These sympathetic
arcs have a collateral connection with the abdominal
muscles by way of the reflex through the anterior
horn cells. This the visceromotor reflex of Mac-
Kenzie and rigidity of the muscles results from its
stimulation. Rigidity stimulates fibers of deep sensi-
bility and tenderness results. There is a type ot
case which manifests a well defined syndrome that
I would incorporate in this classification; and since
I have neither text-book nor reference with which to
substantiate my conclusions, I beg that you accept
my offering as a suggestion and not as an announce-
ment. My conclusions are based upon the phe-
nomena just cited, and my references are to those
cases wherein we can eliminate focal infections, such
as teeth, tonsils, sinuses, stomach, gall-bladder, pros-
tate, etc., as also endocrine and blood dyscrasias.
These cases are without a previous history of an
acute abdominal trouble, but they might perhaps
have had early in life a slight gastro-intestinal dis-
turbance, but nothing very marked in an acute way,
although this particular phenomenon I am about to
cite I have noted in a number of cases. The pa-
tient will perhaps complain of a neuritis, possibly an
intercostal neuralgia, or perhaps pain confined to
the cervical muscles or muscles of the back. In
examining this patient the feature that strikes our
attention principally is the continuous hypertension,
a hypertension that is a reflex phenomenon due to
a vasomotor disturbance and a splanchnic engorge-:
ment. Continuing our physical examination and get-
ting down to a point that corresponds to the junc-
tion of the ileum and cecum, we find on deep sus-
tained pressure a crepitation that is almost audible.
This condition is a reflex spasm of the ileo-cecal
valve brought about by the relation of the sympa-
thetic afferent to the efferent sympathetic cells, caus-
ing inhibition of the gut-wall. Sustained pressure at
this point brings about a relaxation by blocking the
paths of the peri-neural lymphatics and invariably op-
erative measures prove conclusively the presence of
some type of adhesive membrane adherent or retro-
flexed appendix. Our symptoms are not acute, but
a condition in which hypertension is marked and in
which the output is somewhat lessened, heavily
loaded with phosphates and the presence of indican.
Operative measures correct this condition. Time for-
bids further details. In a classic paper on the treat-
ment of inoperable cases of ileus. Dr. Escomer of
Peru recommends the administration of liquid vase-
lin in dram doses, oft repeated, and in the irreducible
cases of hernia in the old he employs the addition of
pituitrin. I would ask if any one present has had
experience with this line of treatment in inoperable
cases.
Dr. E. C. Junger, Soldier — I wish to discuss the
subject of the acute abdomen from the standpoint of
the general practitioner in a small town. We do not
all live on trunk lines and a great many of us do not
have any Sunday train, and there are many week-days
when we do not know whether we will have any train
or not. And some of these acute cases will occur on
Sunday when we cannot get anywhere or get any one
to us and we are up against it. While we are gen-
eral men, and supposed to be pretty good in some
things, and in a general way fair in everything, still
if we have too much conscience, as quoted here to-
day, I think we will be made cowards in some re-
spects by relieving our conscience and taking the re-
sponsibility that is put on a man in a small place that
some of the men in the larger places do not have. If
you will allow a personal reference, I had an acute
abdomen myself a couple of months ago that came
on on Sunday morning. And while it was con-
sidered wrong to use a dose of magnesium sulphate
or morphin, still the trusty old nurse came up and
administered magnesium sulphate to me, I promptly
gave it up. Then I thought I would try the other
method with the morphin and put it under the skin
so it couldn’t get out, and that gave me some relief.
However, this is only in passing. But we have these
conditions coming up, and therefore, I am pleading
for the general practitioner in the small community
who does not have the facilities of the larger places,
where we and our patients develop pathology and
cannot get anywhere and the specialists cannot get
to us. We need some way of educating our people
so that they will have more confidence in us, and act
on our judgment, and not leave us in a place where
we are afraid to divert from the regular method of
doing things because we would be blamed. We
would like to have some education going on through
the Journal or by way of propaganda, because many
doctors in these small towns do not keep up and we
do not have their cooperation if results are not satis-
factory, when we get so much more criticism. This
is what we want to get away from so that we will
have a better understanding between profession and
laity and thus be of more service to the people.
Dr. M. J. Kenefick, Algona — The acute abdomen
covers such a multitude of sins that I can not at-
tempt to discuss this paper, but only repeat what I
heard a surgeon of more than national repute say a
short time ago at a medical meeting. In referring
to this refined differential diagnosis of the acute ab-
96
Journal of Iowa State Medical Society
[March, 1922
domen, Dr. Jonas of Omaha said: “When I am led
to the bedside of a patient with an acute abdomen,
and am asked by the attending physician what is go-
ing on inside, I simply say ‘I do not know.’ ’’ There
has been a very scientific discussion here today on
the causes of pain. That is the predominant symp-
tom in all these cases, it is the one thing that brings
the patient to the doctor, or the doctor to the pa-
tient. That is the first symptom and usually the only
one that induces the patient to call in a physician.
Dr. Studebaker of Fort Dodge epitomized this symp-
tom in the acute abdomen a short time ago. A little
Italian boy entered his office holding his hands
across his abdomen, and the doctor said: “Tony,
what is it?” The answer was, “Pain in de bell, hurt
like hell.”
Dr. J. S. Weber, Davenport — There is one type of
acute abdomen we should emphasize, and that is the
acute gangrenous appendix, with possibly an acceler-
ated pulse of ten or twelve beats and no pain and no
rigidity, no elevation of temperature and often sub-
normal temperature. It is very deceiving. Look
back at the cases in which you have opened the ab-
domen for an apparently mild case and see how many
you have found that were acute gangrenous. No one
can tell how grave a case may be until he gets in.
Allow me to cite a little experience just recently, the
case of a physician of our city whom I appendecto-
mized. It was one of those gangrenous cases men-
tioned above. The blood count fortunately showed a
marked leucocytosis. It was the one factor that con-
vinced the physician to have an immediate oper-
ation. The point I wish to make is that had there
been no leucocytosis, which might have been a still
more menacing condition, I doubt very much if he
would have submitted. Ordinarily we lay consider-
able stress upon rigidity, but in these cases the ab-
domen may be perfectly flaccid.
Dr. F. R. Holbrook, Des Moines — We have had
an ample dissertation on “the acute abdomen.” I
believe that very few mistakes are made, for most of
us can diagnose those things. But what I wish to
offer is a confession of faith. Notwithstanding the
classical symptoms and which we all know, three
years ago I was associated on a case where we all
missed it, and it shows that the symptoms can be
missed at times even though they be fairly well
marked. The patient was taken to a large general
hospital and operated on for appendicitis, and about
thirty-six hours afterwards he began to develop ab-
dominal signs; his temperature rose, he began to
vomit, his respirations ran up to about 60 per minute,
and we all thought he had pneumonia. This case was
seen by the chief of the surgical service, a man of
national reputation, the assistant of the surgical ser-
vice, a man of large reputation, and six or eight
lesser lights, myself included. Over a period of
forty-eight hours we saw this man at frequent inter-
vals. We sent for a consultant from the medical side
to look at the case, and he said, “No, he hasn’t pneu-
monia;” and we thought he did not know his busi-
ness. We saw that the patient had a distended abdo-
men, but for some reason it seemed as though that
was a reflex symptom caused by the chest condition.
About twelve hours later we sent for medical con-
sultation again, this time asking for the chief of
the service. He came and brought with him a num-
ber of assistants and went over the chest, and then
said, “No, there is no pneumonia.” In the meantime
surgeons saw the case frequently. The patient died
and we all gathered round the necropsy table. The
condition was suppurative peritonitis caused by sec-
ondary perforation of the ileum about two inches
above the attachment of the appendix. At the opera-
tion the tip of the appendix was adherent to the
ileum and in stripping it off a slight piece of the
peritoneal coat was torn away, and a necrotic spot
developed which caused it to open up. I relate this
case simply “to point a moral and adorn a tale,” as
it shows that occasionally the true condition can be
missed even by men supposed to know acute abdo-
mens when they see them, and who look at them
thoroughly and often.
CHRONIC COLITIS*
C. B. Luginbuhl, ]\I.D., Des IMoines
During the past few years, colitis has enjoyed
something of a vogue, serving its medical friends,
along with neurasthenia, catarrh, and a half score
of other old favorites, as a convenient dump for
diagnostic duds. As a result of the widespread
use and abuse of the term, it has fallen into dis-
repute with some clinicians, who deny the exist-
ence of colitis as a clinical and pathological en-
tity. It is not difficult to understand their ob-
jections to the term colitis, since it has been
loosely applied to cover a variety of functional
disorders as well as diverse pathological changes
in the large bowel. This lack of differentiation
has been responsible for much confusion in diag-
nosis, as well as for a resulting ill-advised ther-
apy. It has accordingly seemed worth while to
attempt to classify, upon an etiological and a
pathological basis, the various types of functional
and organic disorders of the colon usually
grouped under the general diagnosis of chronic
colitis.
The etiological factors are of necessity many
and varied since the diagnosis covers so wide a
territory, but in a general way, these factors fall
easily into two groups. The first and most im-
portant cause of colitis are changes in the intesti-
nal contents. In a second small group of cases,
we have to do with infection or toxins carried bv
the blood stream. In the first group, we may dis-
•presented before the Seventieth Annual Session Iowa State
Medical Society, Des Moines, Iowa, May 11, 12, 13, 1921.
VOL.XII, No. 31
Journal of Iowa State Medical Society
97
tinguish three rather distinct causal types of
colitis: 1, catharsis colitis; 2, stasis colitis; 3,
fermentative colitis. The catharsis habit has be-
come little short of a national institution ; the phy-
sician prescribes a cathartic for this or that rea-
son, or for no reason at all save that he believes
it to be harmless and perhaps useful. The patient
prescribes cathartics for himself upon the same
principal. In point of fact, practically every
cathartic so used is an irritant ; its use induces
hyperemia and increased secretion. If indulgence
in cathartics is only occasional, these changes are
only transient, but if their use is persisted in a
catharsis colitis develops. The colon becomes
spastic, constipation develops, and catharsis be-
comes a part of the daily routine. Catharsis and
constipation, constipation and catharsis become so
intimately associated that the etiological role of
each is difficult to determine.
Stasis in the large bowel, whatever its origin,
may determine inflammation of the colon because
of the irritants which are produced by decomposi-
tion. Stagnation also favors the development of
an abnormal intestinal flora — sometimes abnor-
mal in type, but more often abnormal in the
enonnous increase of the usual intestinal organ-
isms. These organisms and the toxins to which
they give rise are in themselves a source of irrita-
tion while the putrefactive changes for which
they are responsible are productive of still further
irritation. The physical habitus which favors
stagnation in the large bowel, food which leaves
little residue, or which easily undergoes putrefac-
tive changes, in short, anything which favors
stagnation and decomposition is an etiological
factor in the development of colitis.
Fermentative colitis is of minor importance in
so far as incidence alone is concerned, but it is of
peculiar interest because it is so often unrecog-
nized or misinterpreted. Here again the irrita-
tion arises from chemical changes within the
bowel, the product of a peculiar fermentation.
The intestinal contents may in themselves be irri-
tant, as when the ingestion of excess carbohy-
drates results in decomposition and the liberation
of organic acids. In fermentative colitis, there h
a changed intestinal flora, so that fermentation
occurs even when the use of carbohydrates is re-
stricted.
From a clinical standpoint we may differentiate
four types of colitis: 1, simple; 2, mucous; 3, in-
terstitial, and 4, ulcerative colitis. When I say
“differentiate” I would not be understood to
mean that there is always a hard and fast line
which separates one type from another, for in
practice each type has something in common with
its fellows. Yet from a clinical and pathological
standpoint, I believe that each type is sufficiently
characteristic to make this grouping defensible.
In simple colitis, the pathological picture is that
of a functional di.sorder unmarked by organic
changes. There is some hyperemia of the large
bowel, associated with an abnormal or increased
secretion of mucus. These changes may be ap-
parent throughout the colon, but are more com-
monly restricted to, or at least more marked in
certain regions, as in the cecum, the ascending
colon, or the rectum. Clinically, there is tender-
ness over the colon, sometimes abdominal dis-
comfort, .sometimes acute colicky pains ; constipa-
tion is the rule, and under the fluoroscope, spastic
contractions of the colon are usually, but not In-
variably .seen. On examination of the stool a
moderate amount of mucus is usually noted.
This is the clinical pendant of the catharsis colitis
considered under etiology, though simple colitis
may also develop following the ingestion of irri-
tants other than cathartics, in the wake of an
acute colitis or an acute infection. Constipation
is another important factor, both in itself and be-
cause it leads to the use of cathartics.
An abnormal or increased secretion of mucus
is common to all types of colitis, but when I speak
of mucous colitis, I have in mind that type of
colitis in which hypersecretion of mucus is the
dominant symptom. The mucus is sometimes
passed in large masses ; occasionally the inspis-
sated mucus appears in long shreds suggesting
helminths. In rare cases, a cast of the bowel is
passed, having the appearance of a true mem-
brane. As for the pathology, if hyperemia is
present, it has taken on a more chronic form. The
mucus is secreted by the goblet cells of the crypts
of Lieberkuhn, and is discharged from the mouth
of the gland upon the bowel wall The existence
of a constipation or diarrhoea, as well as the con-
sistency and quantity of mucus secreted, will de-
termine the form in which the mucus is passed.
The etiology is far from clear. In this type of
colitis, there is often entire freedom from pain;
when the patient finally does consult a physician,
the subjective symptoms are vague, not closely as-
sociated with the colon, and the history permits
of no definite conclusions in regard to duration
or onset of the trouble, although one gains the
impression that it is of long-standing. In that
type of mucous colitis in which casts of the bowel
are passed during crises of acute pain. Van Noor-
den and his disciples believe that we have to do
with an intestinal neurosis. That this type of
colitis is often met with in neurasthenic and hys-
teric individuals does not seem to me to be con-
98
Journal of Iowa State Medical Society
[March, 1922
vincing proof of a neurosis. Colitis of any type
is frequent in these patients, but the exaggerated
reaction to pain, so common in these individuals,
would account for the crises of pain which at
first appear to set this type apart from other
types of mucous colitis. It would seem that these
attacks are rather exacerbations of a chronic mu-
cous colitis, and that the difference is clinical and
more apparent than real. On the other hand, if
mucous colitis is a late stage of a simple colitis,
there is a missing link of which we have no defin-
ite cognizance. A low-grade infection involving
the epithelium of Lieberkuhn’s crypts may be a
factor, but no detailed study of their pathology
appears available.
In interstitial colitis, there is cellular infiltra-
tion of the interstitial tissues, and proliferation
may be followed by atrophy. The openings of the
glands in the atrophic mucosa may become oc-
cluded, and stagnation of the secretion lead to the
formation of occasional or of innumerable small
cysts, the so-called colitis cystica. Possibly the
occasional case of multiple tiny diverticulae of the
colon forms still another sub-type of interstitial
colitis, but that, as Kipling says, is another story.
The secretion of mucus is usually less abundant,
the other clinical symptoms more severe and ob-
stinate than in the preceding types.
Under suppurative colitis we must include
those cases of ulceration of the colon due to some
specific organism, such as the tubercle bacillus,
the spirochsete pallida, the amoeba dysenteriae. In
a far larger group of cases, the ulceration is due
to infection with one of the usual pyogenic or-
ganisms. Necrosis of the epithelium occurs, per-
haps as the result of pressure from fecal masses,
and the damaged tissues are then invaded by or-
ganisms which are present in enormous numbers
in the stagnating mass. Extensive superficial ul-
cerations may develop, and perforation sometimes
occurs. Circulator)- disturbances may also give
rise to areas of lessened resistance which are then
invaded by pyogenic organisms. Finally infected
and swollen follicles may break down. In ulcer-
ative colitis the mucus is usually, but not always
blood-stained. Msible pus may also be noted,
particularly when the lower part of the colon is
involved.
Diagnosis based upon the existence of consti-
])ation, nausea, dizziness, abdominal discomfort,
and macroscopic mucus in the stools is readily
made, but unfortunately the value of such a diag-
nosis is in inverse ratio to the ease with which it
is reached. It must not be forgotten that these
svmptoms are common to other diseases of the
large bowel, and that the existence of colitis does
not by any means rule out other pathology, in
particular malignancy. Three cases, selected
from our files as typical, are graphic illustrations
of possible errors in off-hand diagnoses based
upon so-called classic symptoms.
A physician had been troubled for some years by
abdominal discomfort after eating. More recently
there had been pain, borborygmus, increasing consti-
pation and a loss of flesh. He was well within the
cancer zone, and feared carcinoma of the bowel, but
recognized his diagnosis as one made of fear rather
than of conviction and entered the hospital for
gastrointestinal examination. The Weber test for
blood on gastric contents and stool was negative; a
moderate amount of mucus was present. The fluoro-
scope revealed a spastic colon and the absence of any
mass. The stool was typical of a fermentative colitis.
The catharsis habit of many years standing was
broken up, and relief from the spectre of cancer and
a turn about face in the matter of diet brought early
and permanent improvement.
The second patient was again a physician who
came in with the conviction that he had a carcinoma
of the bowel. His diagnosis was based upon the
presence of much blood and mucus in the stool, al-
ternating constipation and diarrhoea, abdominal dis-
tress, and an alarming loss in weight. The loss in
weight and pallor were so marked as to suggest
cachexia. Again the fluroscope showed a spastic
colon and the absence of any mass. Through the
proctoscope, the mucosa of the lower bowel was
seen to be covered with blood-stained mucus. Un-
like most of us doctors, he proved to be a docile
patient. Within a few months he had regained all
his lost weight, and has remained in excellent health
since though some mucus is still present in the stool
and there is a flare-up of his old trouble whenever
he falls from grace in the matter of diet.
The third case presents the reverse side of the
picture. A relatively young woman of markedly neu-
rotic type gave a history suggestive of a colitis of
some years standing. There was abdominal dis-
tress, a slight loss in weight, and the stool contained
blood and mucus. The fluoroscopic examination was
negative except for some slight spasticity of the
bowel. Through the proctoscope an early carcinoma
high in the rectum was seen.
The presence of blood in the stool is never con-
clusive evidence either for or against colitis. Ooz-
ing of blood from the mucosa is common to most
types of colitis. Fermentative colitis is the one
exception, an exception which is readily under-
stood when we recall that here the irritation is
due to chemical changes in the stool as the result
of fermentation. The exciting organisms are
probably true ferments rather than any of the
usual organisms, and never invade the bowel
wall. Profuse hemorrhage in an uncomplicated
colitis is rare, but may occur when ulceration is
VoL. XII, No. 3]
Journal of Iowa State Medical Society
99
present. Hemorrhoids and polyps are frequent
sources of bleeding, but their presence does not
rule out malignancy. Hemorrhoids are the rule
in carcinoma of the lower bowel, and their pres-
ence calls for careful exploration of rectum and
sigmoid. Polyps are always subject to suspicion
because of their marked tendency to malignant
degeneration.
While constipation is the rule in simple colitis,
constipation often alternates with diarrhoea in
the more serious forms of colitis, and in fer-
mentative colitis and the severer forms of mucous
and ulcerative colitis, diarrhoea alone is often
present. Macroscopic examination of the stool
is as important as microscopic. The dung-like
appearance of the fresh stool in fermentative
colitis is characteristic; the foaminess which be-
comes apparent when the stool stands for a time
is even more illuminating. On careful inspection
of a formed stool, the intimate admixture of
blood and mucus may point to the colon as the
probable source of the Weber reaction, an im-
portant diagnostic aid where the presence of oc-
cult blood might prove misleading. The coating
of the formed stool with an abnormal quantity of
mucus may point to the lower bowel as the af-
fected area, while the presence of mucus within
the formed stool suggests the cecum and the
ascending colon as the site of trouble. If bac-
teriological examinations are to be made — and
these are at best a difficult task — the material
for study or culture is best secured from the in-
side of a mass of mucus.
Fluoroscopic and proctoscopic examinations are
invaluable diagnostic aids to supplement clinical
and laboratory examinations, but their technic
lends itself moreTeadily to demonstration than to
discussion. Gross pathology of the stomach and
upper bowel having been ruled out, fluoroscopic
examination of the colon following an opaque
enema may reveal a spasticity of the large bowel
suggestive of colitis. Malignancy, except in its
earliest stages, should be revealed by the fluoro-
scope in that portion of the bowel lying above
the pelvic brim. Exploration of the lower reaches
of the bowel through the proctoscope and sig-
moidoscope make it possible to rule out cancer in
that portion of the bowel most frequently at-
tacked by malignancy, and may reveal the path-
ological changes typical of a severe colitis. When
the use of an enema results in acute discomfort
and pain, inflammation and spasticity of the large
bowel is probably present. But always before
the diagnosis of an uncomplicated colitis is given,
we must rule out the gall-bladder, stomach, the
upper bowel, the appendix, and other lesions of
the colon, and must remember that pathology ly-
ing quite outside the gastrointestinal tract may
give rise to symptoms suggestive of colitis.
Ill-advised therapy has done as much as care-
less and incomplete diagnosis to discredit the term
colitis. Mucus as an outstanding symptom has
been erroneously considered a cause, and the at-
tempted elimination of the mucus by catharsis
and copious flushings of the bowel has increased
the irritation. Colitis is no exception to the gen-
eral rule that treatment should be directed to re-
moval of the cause rather than to suppression of
the effect. In the presence of irritation and in-
flammation in any other part of the body, the
principle of securing rest for the inflamed part
has long been accepted as a matter of course, yet
in the presence of a colitis, it is a common prac-
tice to attempt its relief by -further irritation of
inflamed tissues. Stasis in the colon must be
corrected, but this should be accomplished by the
use of a bland anti-constipation diet rather than
by the exhibition of irritant cathartics and copious
flushings of the bowel. The necessity for a non-
irritating diet is common to all types of colitis.
Other dietary requirements vary with the indi-
vidual case, depending upon the degree of irrita-
tion, the presence of diarrhoea or constipation,
the presence of fermentation, and often upon
complication outside the gastrointestinal tract.
Discussion
Dr. Eli Grimes, Des Moines — I wish to re-empha-
size the statement just made as to the too frequent
diagnosis of colitis when its actual pathology does
not exist. We have under observation a large num-
ber of patients who have been treated for years for
a colitis when the pathology is far away from the
colon. While we will not disclaim the presence of
colitis, it is well to bear in mind that it is infrequent
compared to the number of cases so diagnosed. One
of the important conditions back of the so-called
colitis is simple irritation. I do not mean an irritant
such as bad food, etc., but food intolerance of a
toxic nature, this is frequently back of the condition
we call colitis. The usual colitis seen in general
practice is of secondary nature — due to tuberculosis,
to heart disease, to renal disease, and probably more
frequently to focal infection than anything else. So
it is well to bear in mind that these patients who
come in with pain, with mucus trouble, loss of
weight, etc., are not suffering from primary disease
of the colon, but that the condition is secondary to
the general condition, the latter not secondary to the
former. Pernicious anemia is sometimes supposed
to be due to colon pathology.
Dr. G. B. Crow, Burlington — Dr. Adolph Schmidt
put forth arguments in support of the theory that
mucus colitis is of nervous origin, in this: That the
amount of mucus secreted is out of all proportion to
100
Journal of Iowa State Medical Society
[March, 1922
the amount of irritation present in the bowel. On
the ground that mucus is evidence of inflammation in
the bowel, the amount of mucus poured out in these
cases of spastic colitis is absolutely out of all propor-
tion to the amount of inflammatory change in the
bowel. Also in support of the view that mucus colitis
is not of inflammatory origin, is the fact that these
cases do well on a coarse diet, rich in cellulose. It
seems to me that these tw'o points emphasize the im-
portance of the theory that the condition is of ner-
vous origin and not of inflammatory or irritative
origin.
Dr. Walter L. Bierring, Des Moines — I think we
will all agree that the essayist has placed the term
and the condition of colitis on a much sounder basis.
There has been much abuse of the term both as re-
gards therapy and as to diagnosis. While it is true
that there are perhaps so-called functional forms of
colitis, that is, there are disturbances about the ab-
domen attributable to the colon that are more or
less associated with functional conditions, yet I am
sure that in most instances when our conclusions are
based on a careful examination, it will be found that
there is a different basis than purely an instable ner-
vous system. Many an instance of so-called mucus
colitis comes to autopsy with very definite patholog-
ical changes. Whether you regard this condition as
originally an inflammatory process or simply a dis-
turbance in secretion of mucus, there is undoubtedly
more or less fibrosis of the sub-mucosa and atrophic
changes occurring in the bowel which gives rise to
subsequent symptoms. There is much in what the
essayist says about the etiological influence of the
habits of the patient. The use and abuse of cathartics
has done much to bring on bowel disorders, and
therefore the intelligent conception of what the dis-
tressing symptoms signify whether due to abnormal
fermentation, to a spastic condition of the bowel, or
to an atonic condition, will be helpful in our plan of
therapy. I am sure that every case of colitis should
be treated individually, and the limitation of treat-
ment should be recognized in each instance. If pos-
sible every patient should be placed in the hospital
for a period of observation so that both the patient
and the attending physician may become thoroughly
acquainted with the details of the condition, and then
although it may not be possible to completely re-
lieve it, still with intelligent cooperation on the part
of the patient, and recognizing the limits of the di-
gestive ability of the patient, a great deal of improve-
ment at least can be brought about. In that way
we will treat these unfortunates really as patients, do
them some good, and miss many of the mistakes that
we have so often made before in considering them as
neurotics, or as conditions which were not amenable
to treatment.
Dr. H. J. Prentiss, Iowa City — Bearing on Dr.
Bierring’s statements founded on his extensive
knowledge of pathology, it might be of interest to
discuss the question from the anatomical standpoint.
I have three very interesting cases of variations in
the colon which are quite phenomenal. The first
case is not so unusual, as the large bowel did not
pass beyond the right border of the liver, but just to
its edge. The next case is one in which the colon
had grown in such a way that it reached over to the
left side and produced a complete hernia, so that the
cecum, about twelve inches of the large intestine and
about two feet of the small intestine were carried
over into the left scrotum. On lifting the mass out
of the scrotum it reached about half down the left
thigh. The third case revealed a condition I had
never seen: The ascending colon and the small in-
testine with its mesentery had fused with the mesen-
tery of the transverse colon up to the duodenum and
hepatic flexure so that there was an attachment of
only two inches. Therefore when one lifted up the
whole intestine from its resting place in the posterior
abdomen, there was no apparent root of the mesen-
tery of the small intestine, and the large intestine
was entirely free as far as the caecum and ascending
colon were concerned. Another case was one in
which the large bowel, instead of passing down the
left side in the usual way, had attached itself to the
mesentery of the small intestine and crossed from
the left side to the right and dipped down from the
right side. Those are a few of the many marked
anatomical variations which we find.
PL.\X OF THE MEDICAL AND RE-
SEARCH SERVICE OE THE IOWA
STATE PSYCHOPATHIC
HOSPITAL*
Lawson G. Lowrey, A.M., M.D.
-Assistant Director of Psychopathic Hospital, Iowa City, Iowa
The history of the establishment of the Iowa
State Psychopathic Hospital is well known to all
of you. The authorization and legal details are
to be found in Chapter 235, Acts of the Thirty-
eighth General Assembly. At a previous confer-
ence the director. Dr. S. T. Orton, has told you
of the general plan of organization and has es-
pecially considered the extra-mural relations of
the hospital.
The hospital is administered by the State Board
of Education. The representative of this board
at Iowa City is the president of the State Uni-
versity. Directly responsible for the medical
school and its hospitals (to which group the
psychopathic hospital belongs) is the dean of the
medical school. So much for the general admin-
istration with which I shall not further deal.
All medical activities of the hospital are under
the control of the director, who is also charged
with certain other duties: First, as scientific ad-
visor to the state institutions, upon request of the
board of control or the superintendents ; and sec-
*Read at the Quarterly Conference of the Board of Control of
State Institutions, March 8, 1921.
VoL. XII, No. 3 1
Journal of Iowa State Medical Society
101
ond, as professor of psychiatry in the University
Medical School, to teach neuropathology and psy-
chiatry in the various divisions of the university.
The duties of the Psychopathic Hospital are in
effect fourfold, namely;
Functions which may be described as “medical
service.”
1. The early diagnosis of mental disease and
defect.
2. The treatment of acute and curable case.«>,
and proper disposition of other cases presented
to it.
Functions which may be described as “educa-
tional and research service.”
3. Investigation into the nature, causes, treat-
ment and prevention of mental diseases.
4. Instruction, or educative.
It is with our plan for carrying out these four
functions that I am concerned today. As the
functions cannot be sharply separated — the re-
search of today forming the basis of medical
practice tomorrow — and since the two sets are
carried on by every person connected with the
institution, I must first describe the general plan.
The work is allocated among four services :
1. The ward service.
2. The out-patient service.
3. The social service.
4. The laboratory service.
Of these, the fourth takes in most of the re-
search functions, though each of the others will
contribute largely as time goes on.
So far as their relations to the patients are con-
cerned, these services are coordinated by the as-
sistant director, who is therefore responsible to
the director for the routine functions of the hos-
pital. The director retains immediate supervision
of all instruction and research work. The assist-
ant director also assists with the teaching; in ad-
dition, does all the departments’ consultation
work in private cases ; and will have direct charge
of the neurosyphilis clinic, where modern meth-
ods of treatment will be carried out.
The ward service comprises two medical ser-
vices ; the nursing service, the dietitian’s service,
and the housekeeper’s service.
Each medical service is composed of a “resident
psychiatrist,” and an “interne in psychiatry.” We
hope to have a definite progression for each per-
son on the medical service. If so, each would
spend one year in each post; i. e., junior interne
in psychiatry, senior interne in psychiatry, junior
resident psychiatrist and senior resident psy-
chiatrist. Each resident will have charge of a
psychiatric or medical “service,” comprising thir-
ty-one beds, and will be responsible for the proper
study and treatment of all cases admitted to it.
He will also serve as instructor in psychiatry in
the medical school. He will train the interne as-
signed to the service, and direct his work.
The two medical services will be responsible,
between them, for the operation of the pharmacy
and clinical laboratories and of three special treat-
ment departments ; namely, hydrotherapy, elec-
trotherapy and occupation-therapy. The equip-
ment for each of these will be amply sufficient
for the needs of the institution.
The pharmacy and clinical laboratories together
will occupy one double room on the first floor of
our central building, opposite the offices of the
physicians. Hydrotherapy will be carried on in
the wards, where facilities will be provided for
giving prolonged baths and various types of
packs, and also in special hydrotherapy quarters
in the basement of the east wing. Here will be
provided a large room for the douches and the
various kinds of partial baths ; a steam room and
a massage room. This hydrotherapy equipment
is near the out-patient quarters and may be used
for out-patients as well as house cases.
The electrotherapy equipment will occupy a
small room on the first floor of the main building
where it is accessible for both sets of wards and
for out-patients. The modern forms of electro-
therapy are, to a large extent, unknown quantities
in the treatment of mental cases. Twenty years
ago many hospitals put in up-to-date electric
plants for 1:hat period, and in most cases have
discarded them. However, modern develop-
ments in the application of electricity to the treat-
ment of all forms of disease make it worth while
to re-study their possible effects in association
with certain types of mental disorder.
Occupation-therapy wdll be carried on under
the direction of a skilled teacher, chiefly on the
wards, in certain pleasant situations which are
available for such work. With the development
of the department, its larger apparatus and stores
will be housed in either two or three rooms, as
may be necessary, in the basement of the west
wing. We hope to avoid one of the errors which
often creeps into the management of a depart-
ment of occupation-therapy in larger hospitals —
namely, that of focusing attention upon those
workers who are most cooperative and able to
produce articles of economic value. This tends
to stress the economic aspect of occupation-
therapy to the detriment of its therapeutic side.
The patients, we should like to reach with occupa-
tion-therapy or with the type of exercises de-
veloped by Dr. Donohoe and Dr. Bryan at the
Cherokee State Hospital, are not the workers, but
102
those who have fallen into bad habits of activity
and are regarded, often erroneously, as hopelessly
deteriorated subjects, fit only for the back wards
of the hospital. To be sure the chances are that
we shall never have a patient for a sufficiently
long time for such habits to develop, but we hope
to do what we can to stave off any such untoward
trend in our patients.
Five of the six wards will have women nurses
in charge ; one ward for disturbed men will have
only men nurses on it, according to our present
scheme ; and the reception ward for men will
have a woman graduate nurse in charge with
male assistants. The convalescent men’s ward
will have only a woman ; the women’s wards will
be entirely staffed by women nurses. It is our
plan at present to have the night supervisor a
woman with a sufficiency of men nurses on duty
on the men’s wards to care for any situation that
may arise. We hope to be able to employ grad-
uate nurses throughout the hospital, and to fill in
the number necessary to carr}^ on a proper nurs-
ing service with pupil nurses from the University
Hospital. We expect to offer a post-graduate
course in mental nursing for any who may desire
to take it. Our idea in nursing, as in the medical
service in general, is the application of general
hospital standards and methods to our group of
cases. This means going far beyond a custodial
policy and considerably beyond the ordinary gen-
eral hospital nursing service into the sort of nurs-
ing service which the large state hospital procures
from its older and more valuable nurses.
The kitchens and food service will probably be
under the direction of a dietitian. The food ser-
vice in the hospital is admirably planned. Every-
thing is cooked in a central kitchen and all food is
delivered to one place in each wing where it im-
mediately goes on to steam tables. It will be
served from this central location to a diningroom
in which all patients, who can go to the dining-
room, will be fed ; the remainder being fed from
trays which are prepared at the food service
room. In case the food preparation and food
service is under the control of the dietitian wc
shall probably make the superintendent of nurses
responsible for the housekeeping service, which
will care for the wards, the basements and the
central building, including the laboratories and
sleeping quarters. Sleeping quarters are pro-
vided in the building for six people. These are
the resident psychiatrists and the internes in psy-
chiatry, who will occupy four of the six rooms.
The other two rooms are then available for vis-
itors, and particularly for physicians from the
state hospitals who desire to spend from one to
[March, 1922
three months, or more, working in the wards and
laboratories of the hospital.
The laboratory service consists of a group of
six departments, each having a definite and direct
connection with the ward services concerned with
individual patients, but each having separate and
distinct research functions which deal not only
with the individual cases, but also with groups of
cases and with larger problems than the problem
of diagnosis and treatment in the individual pa-
tient. These departments, each of which will
have a competent man in charge with as much as-
sistance as becomes necessary, are chemistry,
pathology, serologjq roentgenology, psychology and
physiology. Dr. Orton will probably retain direct
command of the department of pathology, includ-
ing anatomy. The assistant director will oversee
the work in bacteriology and serology. It is prob-
able that the roentgenologist of the university hos-
pital will be asked to give general supervision to
the x-ray department. A psychologist has been
appointed in connection with the graduate school
of the university, and will draw part of his salary
from the university and part from the hospital.
.A. physiologist is in process of being appointed on
the same terms. A chemist has not yet been se-
cured.
This laboratory service then is designed to
carry on the major research functions of the hos-
pital, at the same time making a direct and val-
uable contribution to ward service and to the out-
patient service.
The social service will have several important
functions ; in assisting the physicians to procure
the necessary data for diagnosis, in follow-up
work on cases discharged to the community ; in
relation to the out-patient service, and particu-
larly in relation to a mobile unit, which we hope
to have, consisting of a social worker, a psychol-
ogist, and psychiatrist. This unit would hold out-
patient clinics in various cities and towns of the
state, and investigate any particular local prob-
lems brought to the attention of the hospital by
various governmental agencies.
For the present, the out-patient psychiatrist
will be drawn by turns from the house service ; as
the out-patient department develops and the de-
mand for such service becomes greater, we expect
it will be necessary to put one man in charge of
the out-patient department with a social worker
and a psychologist especially assigned to it. How-
soon it will be necessary to do this is a question
we cannot answer at the present time.
This, then, is the general plan of organization.
What of the plan of service? Our experience m
Journal of Iowa State Medical Society
VoL. XII, No. 3]
Journal of Iowa State Medical Society
103
small and crowded quarters has indicated an ac-
tive demand throughout the state for the type of
service we wish to give. As Dr. Orton has said,
“We do not wish to duplicate state service as it
already exists, but instead wish to supplement it.”
It is true that we will unquestionably receive
many cases which could equally "well go direct to
the state hospital.
Experience at the Boston Psychopathic Hospi-
tal indicated a well defined field of activity not
reached by the state hospital, since only about 40
per cent of the admissions there were later com-
mitted to a state hospital. In other words, .some-
thing over 60 per cent of the cases were not cases
for the state institution or recovered from their
acute attack with a short period of residence m
that hospital. This means, in terms of patients,
that about 750 patients per year were committed
from the psychopathic hospital to the district hos-
pitals, and about 1250 cases per year were re-
turned to the community. The result is that the
Boston Psychopathic Hospital can offer a diag-
nosis and advice service to a large group of pa-
tients who would not be presented at the district
state hospital for such service.
As already stated, our limited experience of the
past seven months indicates a considerable de-
mand for this type of service in this state. An
interesting point is that 64 per cent of our ad-
missions have come voluntarily to the hospital for
examination, diagnosis and advice. We have
been able to do very little in the way of treatment
because our quarters are small, unsatisfactorily
arranged, and the demand for service so great
that we have not been able to keep patients for a
period of time adequate for treatment.
Our plan is to bring to bear upon every case all
of the methods that have found a place in medical
diagnosis. We are fortunately situated in that
we can call upon the various departments of the
medical school for examination and treatment of
any conditions which fall within their fields of
activity. One of our residents is especially in-
terested in psychotherapy.
Therefore, we expect to do intensive and ex-
tensive work on all patients coming to us, or
reached by our out-patient services; to study the
origin and treatment of mental diseases from all
points of view, organic or functional ; to study
them particularly from the standpoint of the oi-
ganic factors. From such studies we hope to de-
rive information of value for the prevention of
such disorders.
PHYSICIANS WHO LOCATED IN IOWA
IN THE PERIOD BETWEEN 1850
AND 1860
D. S. Fairchild, M.D., F.A.C.S., Clinton
Dr. Archelaus Field
The early life of Dr. Archelaus Field was char-
acterized by extreme privations and strenuous
exertion. Grubbing hazel brush for a garden
si>ot with a hatchet, trapping musk rats and
ground hogs for their pelts ; the former sold as
fur, the latter tanned in wood ashes and water
and soft soap, cut and braided into whip lashes
and sold for revenue; planting and hoeing corn
from seven a. m. to sundown for 25 cents a day;
milking two cows all summer for their two calves
which he trained to be oxen, walking three miles
a day and return to school ; teacher’s certificate
to teach English branches and pedagogy at fif-
teen ; reading medicine and toting medical saddle
bags with some degree of success and popularity
at twenty, are some of the outstanding incidents
in a life that providentially has been extended
well past its ninety-second birthday.
He was born November 15, 1829, his father be-
ing Dr. Abel Wakely Field, a native of Benning-
ton, Vermont; and his mother Zilpha Witter
Field, a native of Ontario county. New York.
He was the eldest of three brothers, all of whom
reached manhood. His brother Orestes G. hav-
ing been a distinguished surgeon of the War of
the Rebellion, and the youngest. Captain James
W., still living, a retired capitalist of Marysville,
Ohio.
In 1839 his parents removed from Ontario
county. New York, to Madison county, Ohio.
His first occupation was that of planting and
hoeing corn for a neighbor farmer for 25 cents
a day from early morning to sundown. There
were no walking delegates in those times. His
first commercial transaction was with his father,
whereby he agreed to milk two cows all summer
and winter for their two calves. These calves
were his first team. He made his own sled and
ox-yoke, and has a scar on one of his shins
where he was hit by a drawing knife in smooth-
ing the tongue of his sled. He also bears another
scar in one of his eye-brows where he was hit by
a refractory hickory stick which he was bending
for an ox-bow.
His first real nice suit of clothes was made up
by his mother. He paid 18 cents a yard for cloth
for the coat, 37 cents a yard for cloth for pants,
both blue check, 7 cents for calico to make a vest,
and 60 cents for silk for a cap.
104
Journal of Iowa State Medical Society
[March, 1922
Between the ages of twelve and twenty years
he attended academies at West Jefferson, Lon-
don and \\Mrthington, always hiring a room and
boarding himself, teaching and working on a
farm at intervals. At fourteen he raked and
bound wheat and oats, keeping up with the cradle
through harvest — a man’s work. His employer.
Judge Burnham of West Jefferson, Ohio, made
him a present of five dollars at the close of the
A. G. Field M.D., L.L.B.
season, this being the first substantial present he
ever received. At the age of fifteen he secured
a certificate for teaching the English branches,
which certificate he still has, dated April 7, 184,5.
He also has his last certificate for teaching, dated
Chillicothe, Ohio, October 31, 1849. In addition
to common branches this latter certificate in-
cluded algebra, natural philosophy, chemistry and
astronomy. All of his traveling was done on foot,
and four days and three nights were consumed on
the road between Frankfort and Chillicothe, with
intensive study of the branches upon which he
was to be examined. The examiner’s name was
Wm. B. Franklin, and the examination was brief
and satisfactory, he receiving a certificate for
two years. His school was to begin in two weeks,
and he returned home to iMadison county for a
short visit, after which he started for school with
his belongings in a small wooden trunk two feet
long and one foot square. He does not remember
any test of physical strength and endurance equal
to that of transporting this trunk, which he still
has. Its position was changed hundreds of times
from beneath one arm to the other, and from the
top of one shoulder to the other, during this jour-
ney over muddy roads and part of the time in the
rain. He also has the trunk which contained his
entire possessions when he came to Iowa in 1849.
In June, 1850, he joined a company of emi-
grants from Madison county, Ohio, to Appanoose,
county, Iowa. There were eleven wagons and
about thirty people. The new experiences were
much enjoyed by all, although an unlucky grass-
hopper occasionally got into the biscuit and ma-
rauding spiders into the blankets. But the mode
of traveling finally became quite monotonous,
especially over the miles and miles of corduroy
bridges through the black swamp of Indiana. A
flat ferryboat at Burlington made several trips
to land the party on Iowa soil. New inspiration
came to all in the invigorating atmosphere of
Iowa, having been on the road six weeks.
Most of the party settled in and about Center-
ville, where the subject of this sketch nailed up
his shingle for practice. People were healthy,
and as there were plenty of older doctors, he had
but few calls. In the early spring of 1851 he was
appointed deputy sheriff of Appanoose county,
and in that capacity assisted in taking the census
of a large part of Appanoose county.
A little later the county seat of Wayne county
was to be located, and George W. Perkins, sur-
veyor of Appanoose county, was appointed as one
of the locating commissioners. Before starting
Mr. Perkins invited the subject of this sketch to
accompany the party, and, without asking why he
did so, he at once joined the expedition. There
were very^ few families in W'^ayne county at that
time — probably not over six or eight, and none
nearer than four and one-half miles from the cen-
ter of the county. The best part of a week was
spent in riding over the wild prairies, occa-
sionally molesting a herd of deer or a flock of
wild turkeys or prairie chickens. Finally, when
selection of a location had been made, Mr. Per-
kins wrote on a piece of paper the numbers of the
land for the future county seat, now Corydon,
also the numbers of two eighties, one east and the
other south of the proposed town site. He said
the commissioners would start immediately for
Fairfield to enter the selected town site, and sug-
gested that Dr. Field go too, but by another route,
and try to secure the two eighties of which he had
given him the numbers. This he did, although he
VoL. XII, No. 3]
Journal of Iowa State Medical Society
105
had less than a dollar in excess of the amount re-
quired to pay his necessary expenses. Bernhard
Henn was then commissioner of the land office.
Dr. Field did not wait for the commissioners; a
good horse solved the problem. He reached the
land office more than a day in advance of the
commissioners and made a confidante of Mr.
Henn, to whom he had no word of introduction.
Mr. Henn accepted the statement of the dust-cov-
ered stranger and at once placed a land warrant
on the proposed town site, lest the commissioners
might be intercepted by some speculator. He
then placed another land warrant upon the two
eighties for Dr. Field, accepting his note for two
hundred dollars and giving him a bond for a deed
in one year, dated May 11, 1851. The commis-
sioners arrived the day following to find the town
site secured.
Returning to Centerville, Dr. Field was offered
a partnership with Dr. Nathan Udell of Union-
ville, afterward state senator. This engagement
was soon terminated by the accidental death of his
father. Dr. Abel W. Field, on the twenty-first day
of August, 1851. He returned to Ohio and at
once took up the practice left by his father. The
following spring he returned to Iowa to pay for
his land and to look it over. The trip was made
by deck passage on a steamboat via Cincinnati,
Cairo and Keokuk, furnishing his own provisions.
He took the railroad from Columbus to Cincin-
nati, and from and to Keokuk he went on foot by
way of Mt. Pleasant, Bloomfield and Centerville.
In the autumn of 1853 he entered the office of
Prof. John Dawson of Columbus, Ohio, matric-
ulated and paid for tuition for the session of
Starling Medical College in 1853-4, and graduated
the following spring, three years’ practice being
accepted in lieu of one course of lectures. To
provide means to start again he had engaged a
school in Brown township, Franklin county, and
as soon as examinations were over went again
into the schoolhouse for one term. In the spring
of 1854 he located in Hillsboro, Highland county,
Ohio. He secured a fair practice, but collections
were slow and insufficient to meet his necessary
expenses. He sold his buggy and a fe\v months
later his beautiful black horse to meet expenses.
The parting with Cola was. Dr. Field says, the
severest trial of the kind of his life.
In June, 1856, he formed a partnership with
Dr. Buchanan in Faircastle, Brown county. Dr.
Buchanan, like many other drunken doctors, had
a reputation far above his merits. Dr. Field had
nothing but ener^, health and fair qualifications,
while Dr. Buchanan had reputation, horses and
business. Dr. Field worked his business for all
these was in it until the autumn of 1856, when he
paid what debts he could, reserveing twenty-four
dollars, called a meeting of creditors at Mr. Hib-
ben’s store, and told them he thought it best for
all concerned that he try another location. They
all gave their consent. No one asked where he
was going and he did not know himself.
He then went to Cincinnati and called upon
Prof. Wm. Dawson, brother of his preceptor. Dr.
Dawson advised him to go south. Leaving his
books, diploma and everything else at Hillsboro
(which no one had asked him to do), he took the
first train to Louisville. Leaving his satchel at
a hotel, he walked toward the river, where he saw
a sign on a steamboat which read : “Tennessee
River This Evening.’’ He returned to the hotel,
got his satchel, which contained- an overcoat, one
shirt and a change of under-clothing, and went on
board the boat. The captain said they would go
to Eastport, Mississippi, and farther if the stage
of water would permit. Dr. Eield paid his fare,
ten dollars, and had less than ten dollars left.
Night came on, and every “thud, thud” of the old
steamboat widened the distance between him and
every one he had ever known. That was a pretty
dark night ! About the fourth day Eastport land-
ing was reached. The town was about two miles
from the landing, and there were plenty of con-
veyances ; but Dr. Field took his little carpet sack
and footed it. Cypress trees with big knees, bales
of cotton, mules and ox teams, old tumbledown
wagons, scantily-clad negroes, sand roads with no
sidewalks, were among the first sights. Every
man was clad in seedy homespun, and carried a
gun. Dr. Eield learned that Jacinto was about
thirty miles distant, that it was the county seat,
and that a stage would leave at seven p. m. He
paid his fare, four and one-half dollars, and
while waiting chanced to step into a drug store.
The druggist. Dr. Klice, was very busy filling
vials with a dirty-looking mixture labeled “Es-
sence of Tar — A Cure for All Summer Com-
plaints.” Dr. Eield opened a vial, and after casual
examination the druggist asked if he could tell
what it was made of. Dr. Eield replied that creo-
sote was the active principle, with solution of e.x-
tract of licorice and aromatic oil. He said, “You
are a doctor.” Dr. Eield replied, “Yes, I am a
sort of doctor.” Nothing more was said, but in
about half an hour he introduced a man whom he
said had had sore eyes for a number of years, and
asked Dr. Field to prescribe for him. Dr. Field
asked permission to go behind his counter, com-
pounded a prescription and gave him a treatment.
The patient, one Rutledge, asked for the bill. Dr.
Field held his breath while he said, “five dollars,”
106
Journal of Iowa State Medical Society
[March, 1922
having never charged over 50 cents in his life for
a prescription. Rutledge paid it with an air that
indicated that it might have been twenty.
Dr. Field now had about eight dollars. The
stage station at Jacinto was reached the next
morning. Dr. Field told the landlord. Robert
Davenport, that he ’vas a doctor and had come
to live there, but he did not have a medical book,
a dose of medicine, or anything else to identify
himself with the profession. Everything, even
spare clothing, had been left at Hillsboro. The
same afternoon the landlord asked him to pre-
scribe for his mother, who had some affliction of
the throat. Next day a summons came from a
doctor to visit one of his patients with him. The
woman had retained placenta after delivery. Dr.
Field called for a pan of warm water, and in five
minutes removed the source of trouble. He had
another call the same evening, two or three the
next day, and from that time on had plenty ot
business.
The horses were of poor quality, but every one
was willing to loan a horse to the young doctor.
After about three weeks he saw a man riding a
fine large horse across the public square. One of
his patients was a dry-goods merchant by the
name of Jim Dobbins. He said to him: “Dob-
bins, I saw a horse today that I would like to
have.” Describing it to Dobbins, the latter said :
“That is Gillenwater’s horse.” Nothing more was
said until the next day, when Dobbins came to the
hotel and said: “Doc, I have got that horse for
you.” Dr. Field replied, “I am sorry, for I have
nothing to pay except a silver watch and six dol-
lars in money.” Dobbins answered : “All right.
I will take your watch on the deal, and you keep
your money.” Dr. Field took the horse, and in
six weeks paid Dobbins the last of $150 for him.
Business increased beyond expectations, and
Dr. Field saw no patient who died, either his own
or in consultation, until after he had done over
$1300 worth of business. He was careful to at-
tend strictly to his own business without reference
to local social or political conditions. Northern
teachers and preachers going south had usually
shown aversion to local affairs, especially to
slaver)'. But Dr. Field cut out everything of the
sort and, without taking any position on such mat-
ters, even when artfully suggested by negroes,
soon had the unstinted friendship of every one.
In about three years he had a nice plantation of
240 acres containing an extensive peach orchard,
another of eighty acres, town property in Boone-
ville, ten miles distant from Jacinto (where he
kept an extra horse for exchange), had paid off
his old debts in Ohio, sent money regularly to his
mother, and says he never knew what disinter-
ested friendship was until he went south.
But the war cloud was rising in the horizon,
and Dr. Field thought it best to return north. In
March, 1859, he returned to Corydon, Iowa, visit-
ing his mother in Ohio on the way. Property ac-
cumulated in Mississippi was about three-fourths
sacrificed in exchange for wild land in Crawford
county, Iowa. He soon had a good practice at
Cor)'don. In 1860 he was elected president of the
Wayne County Agricultural Society, and so in-
cidentally became a member of the Iowa State
Board of Agriculture, a meeting of which he at-
tended at Des Moines during the winter of 1861,
stopping at the Grout House in East Des Moines,
kept by T. E. Brown and his father-in-law, Mr.
Marsh. The topography of the city, with bottom
grounds at confluence of the rivers, surrounded
in every direction by the well-shaded hills for res-
idences, was to his mind very beautifully adapted
to the requirements for a city, and before leaving
he had decided to make it his future home.
Thither he removed in July, 1863, but soon left
for New York for its professional and educa-
tional advantages. At that time the elder Austin
Elint, James R. Wood, Frank Hamilton, were in
the Bellevue faculty, Valentine Mott, Sr., in the
University of New York, and Alonzo Clark,
Thomas H. Marcoe and Willard Parked in the
College of Physicians and Surgeons, medical de-
partment of Columbia University. To hear these
celebrities Dr. Field matriculated at all three of
the above-named medical colleges, his diploma ex-
empting him from paying fees for tuition. From
the last-named institution he again graduated in
the spring of 1864. The class of 250 consisted
largely of graduates of other institutions, M.D.,
A.B. or A.M. Dr. Field’s name was presented at
a class meeting as candidate for valedictorian.
His opponent was Jas. H. McClain, afterward
elected to the chair of practice and president of
the faculty. He was defeated by a majority of
seven votes, and this defeat Dr. Field always
regarded as one of the most flattering as well as
most fortunate incidents of his life, because had
he been elected he could not have met the ex-
pectations of the class.
While in New York he was also a student in
Bronson School of Elocution in Cooper Institute.
Returning to Des Moines in May, 1864, Dr.
Field secured office rooms in the Savery Hotel,
now the Kirkwood, just opposite the hotel office,
where it took him seven months to discover that
the rank and file of citizenship in a city, such as a
doctor must depend upon for patronage, is not
reached by an office in a big hotel. He then had
VoL. XII, No. 3]
Journal of Iowa State Medical Society
107
an office built on leased ground on Third street
near Court avenue, and soon had a satisfactory
patronage.
W. H. Lease, a gentleman and a scholar, was
then mayor. The medical men were Drs. C. H.
Rawson, H. L. Whitman, W. P. Davis, Isaac
Windle, W. H. Molesworth, W. H. Dickinson, W.
H. Ward, A. ]\I. Overman, J. O. Skinner, Geo.
and Frank Grimmel, David Beach, D. V. Cole,
T. K. Brooks, H. H. Saylor, S. A. Russell, etc.
Drs. Hanawalt, Wiley, Cox, Grimes, Carter, Steel
and others came later. Dr. Field sold his office
to the Western Stage Company. Third street was
noisy all night by the arrival and departure of
100 stages, more or less, from all points of the
compass. The building still stands and is one of
the second-hand junk shops on Third street.
After some years the ground was needed for
larger buildings and the office was moved to Mul-
berry street, west of Thirteenth street, and sold
for a residence.
The population of the city was about 7,500.
The first one-horse express wagon was brought
by a man named Davis, who distributed hand-bills
announcing the fact. About a year later a number
went out east where the Redhead residence now
is to meet and welcome the first railroad, now
the Keokuk division of the Rock Island.
Rev. Thompson Bird, a typical Presbyterian
minister, had organized the Presbyterian church.
Will Lehman worked the organ and Major Geo.
North led the choir, in which were Louisa Bird,
now Mrs. Hyde, Pauline Given, now Mrs. Al.
Swalm, and a number of others whose names are
forgotten. The major often had some difficulty
to preserve good order. The frame church build-
ing stood north of the first alley south of the
Savery^ House, now the Kirkwood, and a nice dis-
tance back from the street. Mr. Bird said it had
been built mostly by his own church members.
WTile not pretentious, it was good and ample for
the time. It was destroyed by fire. Mr. and
iMrs. A. Newton, Mr. and Mrs. West, Mr. and
Mrs. C. P. Luse, Mr. and Mrs. Tac Hussey, were
among the members. Dr. Field had brought a let-
ter from Dr. Steel’s church in Hillsboro, Ohio,
and became a member. The congregation soon
after became desirous for a change of ministers,
some claiming that Dr. Bird’s delivery was not
good. With deep regret and sorrow Mr. Bird fi-
nally resigned and Dr. Field took a letter to the
Congregational church. Mr. Bird’s church had
all sorts of trouble to find a minister to their lik-
ing. There were a number of meetings to con-
sider different candidates. At one of these some
one proposed a name with the remark that no one
here knew anything about him. Dr. T. K.
Brooks at once said, “That is the man for us. We
want a man that no one has ever seen or heard
of.”
In 1865 Dr. Field was elected city physician,
and in 1866 physician for Polk county, and as
such had incidentally something to do in locating
and establishing the present county farm and
county infirmary'. In 1866 he was also appointed
U. S. examining surgeon for pensioners, in
which office he continued, either singly or as
securetary of the board of examining surgeons,
for eight years. Upon resignation he was ap-
pointed upon the board of review in the pension
department in Washington, and removed to that
city in 1882. He resigned as a member of the
review board to continue his work in the Keokuk
Medical College, having been elected to the chan*
of physiology and pathology, where he had given
one course of lectures the year previous, by gov-
ernment rules not being allowed to hold two lu-
crative positions at the same time. His rating in
the department at Washington was so high that
he thought he would be restored any time he
should apply. In this he was disappointed. In
1885 some dissatisfaction between the faculty and
management of the Keokuk Medical College re-
sulted in withdrawal and establishment of another
college. There was, of course, considerable feel-
ing manifested on both sides, and Dr. Field witn-
drew entirely from both. He was elected secretary
of the Iowa State Medical Society in 1869, 1870
and 1871, and in 1872 was elected president. In
1876 he was elected by the Iowa State Medical
Society delegate to and attended the International
Medical Congress in Philadelphia. He was twice
elected by popular vote mayor of the town of
North Des Moines, and during both terms the
affairs of the town were conducted without a
law-suit or a dollar bonded indebtedness. In
1868 he was elected coroner of Polk county, and
in 1878 treasurer of the Forest Home School
District, which position he resigned while in
Washington.
In 1864, the Savery', now the Kirkwood, was a
large hotel for the City of Des Moines. All its
appointments were of the best and its social cir-
cles were of high order. The “wee small hours”
of the night were frequently encroached upon by
protracted social enjoyment, and “battle cry of
freedom,” in which all joined at intervals, re-
echoed through the spacious halls. These gaieties
were sometimes rather too florid to meet the ap-
proval of the staid dignity of Ex-Governor R. P.
Lowe, then supreme judge, who on one occasion,
retired early to his room and locked the door.
108
Journal of Iowa State Medical Society
[March, 1922
Mrs. J. C. Savery, being the most wieldy of the
crowd, was pushed in through the transom over
the door and the judge was compelled to emerge
and resume his place in the circle. IMajor Cav-
anaugh, E. E. Ainsworth, George Gardner and a
score of other good fellows were then denizens
of the Savery.
Dr. Eield has been an active member of va-
rious medical and scientific societies, including
the American Medical Association, American So-
ciety of Microscopists, American Association for
the Advancement of Science, etc. Charter mem-
ber Iowa Academy of Sciences. He is ahso a
member of the Iowa State Bar Association, hav-
ing taken a course in the law department of Simp-
son CentenaiA’ College and received the degree of
L.L.B. in 1879, at which time he was also ad-
mitted to the supreme court, but never engaged in
the practice of law.
In 1869 he invented an instrument for imping-
ing the spray of medicinal substances directly
upon the mucous surfaces of canals and cavities,
illustrated and described in the May Number,
1869, of the IMedical and Surgical Reporter, Phil-
adelphia. Some other publications are as follows ;
“Report on Spotted Fever,” Transactions of Amei-
ican Medical Association, 1865; “Hernia in Children,”
New York Medical Record, September, 1869; “.Ano-
malous Human Head,” St. Louis Medical and Sur-
gical Journal, March, 1867; “Medical Aspect of
Iowa,” Chicago Medical Journal, ^larch 22, 1867;
“Decapitation at Transverse Presentations,” New
York Medical Record, April, 1868; “History of Medi-
cation by .Atomized Medicinal Substances,” Report
to the .American ^ledical .Association, 1868; “Puer-
peral Convulsions and Gl>'cogenesis,” Clinic Cincin-
nati, Ohio, April 1874; “Present Attitude of Medical
Science,” president’s annual address Iowa State Med-
ical Society pamphlet, 1872; “Elimination in Dis-
ease,” Northwestern Medical and Surgical Journal,
St. Paul, .April, 1874; ‘Alildews on Grapevines,’’ Iowa
School Journal, July, 1874; “Physiology and Hy-
giene as a Branch of Popular Education,” report of
committee, Iowa State -Medical Society, Sanitarium,
New "S’ork, September, 1875; “Cellars and Diph-
theria,” New York Aledical Record, December, 1875;
“Doctors and Newspapers,” before Iowa State Med-
ical Society, rejected, Tilden’s Journal of ^lateria
Medica, New York, January, 1876; address before
annual meeting of the Iowa .Association Railway-
Surgeons, Railway Surgeon, November, 1903; “Criti-
cism of Brown Physiology,” slip to school board,
Des Moines.
In 1895 he devised a “Musculotension Meter”
to determine the e.xtent of .softening of muscles in
paralyses, manufactured by Truax, Green & Co.,
Chicago, Journal of .\merican Medical .Yssocia-
tion. In 1889 he devi.sed a universal stand for
microscopy, photo-micrography and copying, il-
lustrated and described in Photographic Mosiacs,
New York, 1890. In 1897 he successfully photo-
graphed through a six-inch Clark telescope a
five-inch image of the moon, showing mountains
and craters in considerable detail, without the aid
of any special lens or other accessory except a
box camera; Popular Science, New York, Janu-
ary, 1898. .At the meeting of the .American Med-
ical Association in Baltimore, 1895, before the
ophthalmic section, and also before the Columbus
meeting of the .American Association of the .Ad-
vancement of Science, he read a paper on “Bright
Light in School Rooms a Cause for Alyopia,”
with proposed remedy and means for measuring
the intensity of light in school-rooms. This pa-
per was an attempt to show the fallacy and dam-
age of the popular doctrine that “the more light
in the school room the better,” and that the abuse
or careless use of such bright light, together witii
near vision, are responsible for a very large per
cent of the myopics who emanate from the
schools. The subject was illustrated by a rec-
tilinear photographic lens, to show that back
focus recedes with reduction of the diaphragm.
The stimulus of bright light contracts the iris and
thus reduces the pupil or diaphragm of the eye,
thereby elongating the eyeball. Near vision does
the same thing, and the persistent strain thus
placed upon the accommodative apparatus results
in the immobility which constitutes myopis or
near sightedness, which being long continued as
in school room work, overcomes the natural elas-
ticity of the accommodative apparatus, and per-
manent and incurable myopia results. The in-
telligent and careful use of proper shades to
modify the light, and free use of distant vision
by blackboard exercises, are recommended as pre-
ventatives. Published in the Journal of .Ameri-
can Aledical .Association, .September 21, 1895;
also svnopsis in Popular .Science, New ATrk.
July, 1895.
He began exjieriments in photo-micrography in
1883 and is one of the pioneers in that line ol
work. Of late he has given considerable atten-
tion to the microscopy of the natural sciences, in-
cluding biology, histology, bacteriology, etc., and
it was with a view to popularizing that line of
work that the Des Moines School of Technolog}'’
was organized in 1884, which has not yet been
pushed to success. .At various times he has ap-
peared before medical and scientific societies, il-
lustrating the subjects treated of by photo-micro-
graphic lantern slides of his own production, in
which line of work he has acquired a considerable
degree of proficiency.
In May, 1877, he married Hattie Weatherby,
VOL.XII, No. 31
Journal of Iowa State Medical Society
109
daughter of Edmond W'eatherby of Cardington,
Ohio, bom in Seneca, New York, and Orrel
Sawyer Weatherby, a native of Yates county,
New York. Three children have been born to the
union, Dalton Arthur, born December 19, 1884
being the only survivor, who is manager of a
large fruit association in California.
In religion Dr. Field is Calvanistic Presbyter-
ian ; in politics a prohibition republican.
Dr. Field has been no small factor in the build-
ing of Des Moines. He located and gave the
ground for Eleventh, Twelfth and Thirteenth
streets from University avenue to Forest avenue.
He has built more than a mile of paving, more
than a mile of sewers, more than a mile of side-
walks, more than a mile of curbing at an outlay of
more than sixty thousand dollars. In addition he
has built nineteen good eight and nine room
houses that are among the good.residences of the
city. They are well shaded by old gigantic elms,
some of which have a circumference of fourteen
feet three feet from the ground, and with branches
that spread more than eighty feet. By buying
small places north of North street he has been
enabled to locate and establish Eleventh, Twelfth
and Thirteenth streets to Forest avenue. All this
he has done single handed and alone and without
misunderstanding or controversies. In business
he has been careful to have a clear understanding
to deal only with those of good business reputa-
tion and to be always ready to perform his part
of the contract to the letter.
Retrospectively, Dr. Field can say that if he
could live his live over again the chances are that
on the whole he would not be likely to do better.
While he is conscious of having prolonged some
useful lives, he is conscious also of many short-
comings in which he did not do his best, and in
which he might have been more kind and con-
siderate to his friends and to those near and dear
to him ; and he is not unmindful of the scores of
noble and faithful horses that in seventy years of
active life have been helpers and in hundreds of
instances his only companions.
Dr. William Watson
William Watson, M.D., for almost half a cen-
tury one of Dubuque’s most prominent physi-
cians, was born in Leeds, England, May 14, 1826.
He was the son of Joseph and Ann (Metcalf)
Watson. When he was a year old the family im-
migrated to the United States, settling in Middle-
town, Connecticut. Four years later the Wat-
sons, removed to Onondage county. New York,
where they remained until he was eighteen years
of age. Here he received a common school edu-
cation. In 1844, William hearing the call of the
West went on alone to Ohio where he taught a
district school. Soon moving on however, he took
a lake steamer one sunny spring morning and
came to Beloit, Wisconsin, settling on a farm
some sixteen miles from that frontier town.
After working hard for two years at the carpen-
ter’s trade, which he had managed to learn back
East, he saved sufficient money to provide for
himself the opportunity of attending the Beloit
Seminary for one year. This year of schooling
was indeed a happy one for our subject for work-
ing at his trade mornings and evenings and Sat-
urday afternoons, he combined with the space of
a single day the experience that comes not only
from the study of books, but also from the wider
fields of actual labor among men of many classes.
Two years after his first arrival at Wisconsin,
Watson’s father came to join him in the new
region.
In 1849, Watson commenced reading medicine
in the country and twelve months later went back
to Beloit to read with Dr. E. L. Clark. The fol-
lowing winters in 1851-2 he attended a course of
lectures in Rush IMedical College, Chicago. With
this preliminary medical education he began the
practice of medicine in the small town of Mc-
Gregor, Iowa, the first physician to locate at that
place. Eighteen months later with the stern expe-
riences of the early doctor picked up amidst the
hills of McGregor he attended a second course
of lectures at Rush Aledical College, graduating
with honor in Eebruary, 1854. Two months after
his graduation he came to Iowa and according to
his own statement “stuck out a shingle in Du-
buque in 1854.” After a few months in Dubuque,
Dr. R. S. Lewis, at that time a prominent physi-
cian of the city, recognizing his worth both as a
physician and a man, formed a partnership with
the energetic young doctor and that partnership
was dissolved only by the death of the white-
haired Lewis on the tenth of September, 1859.
From that date Dr. Watson was always alone in
practice and rapidly built up a medical business
the equal of many of our leading physicians or
surgeons of the present day. No man in Iowa
has been more assiduous in the duties of his
profession.
With the outbreak of the Great Rebellion, Will-
iam Watson hearing the call of his country en-
tered the army as a surgeon of the Eleventh Iowa
Infantry on the 20th of October, 1861. On
March 4, 1863, after active service on the field
he resigned from this post to accept the position
of assistant surgeon of United States Volunteers
under appointment of President Lincoln and was
110
Journal of Iowa State Medical Society
[March, 1922
immediately commissioned by the secretary of
war for responsible hospital duties at ^Memphis,
Tennessee. In August of the same year he was
placed in charge of the Jackson hospital, the next
month was promoted to surgeon of volunteers and
ordered to Louisville, ^Jxentucky. In February,
1864, he was placed in charge of the Crittenden
Hospital and thirty days later sent to Rock Island.
Illinois, to take charge of the post and prison hos-
pitals located there. It was an important assign-
ment, requiring great diplomacy and tact. He
remained in charge at Rock Island until mustered
out on the twentieth of October, 1865. Return-
ing to Dubuque he received a brevet commission
of lieutenant-colonel leaving the army with a truly
bright record. Governor Kirkwood when he en-
trusted the care of a regiment to Dr. Watson
made no mistake in his man for later we are told
that if there was a place where disaster had
caused an accumulation of sick and dying or if
lack of foresight had failed to arrest the spread
of disease, or to provide for the wounded, it was
to Medical Officer M atson they turned with con-
fidence for assistance and support.
In politics Dr. M'atson was a democrat until
the republican party was organized, at which time
he changed his view and clung tenaciously to the
latter party. He never sought office. The doc-
tor was an Odd Fellow and was a representative
to the Grand Lodge on numerous occasions. He
was a member of the Dubuque County Aledical
Society and of the State Medical Society and
served as president of both. He was a president
of the State Medical Society in 1868 when it held
its first annual meeting at Des Moines. He
served as delegate to the International Medical
Congress which met at Philadelphia, in 1876. As
a parlimentarian in the Iowa State Medical So-
ciety he was a recognized power. His knowledge
of the constitution and by-laws of the State So-
ciety, keen analysis and recollection of yearly
amendments, has probably never been equalled.
In the meetings of the American iMedical Asso-
ciation, Watson of Iowa, when he arose to speak
needed no introduction. In this state Dr. Watson
is especially remembered for his sterling worth as
a man, for his keen enthusiasm in his work, splen-
did memory and general prominence in affairs of
the Iowa State iMedical Society. He has written
a number of valuable historical sketches of some
of the lives of the early pioneer physicians. For
years he remained the nestor of the Dubuque
County Medical Society.
Dr. M’atson was first married in Portland,
Maine, in Xovember, 1860, to Miss Lucy Gid-
dings, who died on the 13th of iMarch, 1862, leav-
ing one child, Fred. He was married a second
time on the fourteenth of September, 1868 to
Miss Lucy F. Conkey of Dubuque. He remained
in active practice in Dubuque until 1901. Since
then, and up to the time of his death he traveled
extensively, visiting in the course of his wander-
ings every state in the union. Hale and hearty to
the end he was a splendid type of a true gentle-
man of the old school. His aristocratic appear-
ance on the streets of Dubuque is oft remarked
by the younger generation of physicians. He died
on the twenty-first day of November, 1910, at the
home of his son F. J. M'atson, Thatcher avenue.
River Forest, Chicago. His body was brought to
Dubuque and buried in Lindwood cemetery. His
passing marks the last of our early Iowa doctors
many of whom were engaged in laying the foun-
dation of city and state as well as practicing their
profession.
ROCKEFELLER BOARD AIDS BRUSSELS
UNIVERSITY
The Rockefeller Foundation has announced a con-
tribution of 43,000,000 francs toward a budget of
100,000,000 francs for new buildings and endowments
for the medical school of the University of Brussels.
Part of the fund will go to the establishment of a
nurses’ training school in memory of Edith Cavell
and of Madame Depage, who with the Queen pf
Belgium headed the activities of the Belgian Red
Cross during the early part of the war. The class
rooms of the new buildings will be on a new site on
the Boulevard de Waterloo, adjoining the municipal
hospital of St. Pierre, which wdll also be built and
reorganized to sen-e as the teaching hospital of the
University.
PRECAUTIONS AGAINST ENCEPHALITIS
LETHARGICA
England has issued a memorandum relating to per-
sonal contact in cases of this disease:
The other occupants of a house in which a case of
encephalitis has occurred or is being treated may be
assured that the disease is one of low infectivity, and
that very little risk is run by association with the
patient. At the same time it is desirable that such
association should be limited to what is necessary
for proper care and nursing, and the patient should
be well isolated in a separate room.
School children in the affected household may be
kept from school as a precautionary measure, for
three weeks after the isolation of the patient. There
is no necessity to place restriction on the movements
of other occupants provided they are frequently ex-
amined and remain well. Those in contact with the
case, however, should be advised to use antiseptic
nasal spraj’s or douches, and to gargle the throat
with solutions such as those advised for influenza.
VOL.XII, No. 3]
Journal of Iowa State Medical Society
111
tlte Journal of tfje
Sotoa ^tate illettcal ^ocietp
D. S. Fairchild, Editor.... ....Clinton, Iowa
Publication Committee
D. S. Fairchild Clinton, Iowa
W. L. Bierring Des Moines, Iowa
C. P. Howard Iowa City, Iowa
Trustees
/. W. CoKENOWER Des Moines, Iowa
T. E. Powers Clarinda, Iowa
W. B. Small Waterloo, Iowa
SUBSCRIPTION $2.75 PER YEAR
Books for review and society notes, to Dr. D. S.
Fairchild, Clinton. All applications and contracts
for advertising to Dr. T. B. Throckmorton, Des
Moines.
Office of Publication, Des Moines, Iowa
Vol. XII March 15, 1922 No. 3
A NEW EVANGELIST AND HEALER
A new competitor in the field of psychic heal-
ing has appeared in the person of Mrs. McPher-
son of San Jose, California. She appears in the
double role of an evangelist, and healer. It is
not clear which stands first but one would con-
clude that they were associated, so that one may
supplement the other. The power of miraculous
healing to give greater force to her preaching, and
her preaching, her attractive person, her manne’.',
and her air of mystery to intensify the psychic
influence as we have so often seen, under so-
called Christian science healing.
Mr. King in the Congregationalist, reviewing
her work is inclined to give Mrs. McPherson
credit for honesty of purpose and faith in her
power to heal. Yet we cannot escape the belief
that her case will not differ from so many that
have appeared in the past ; that of degenerating
into a commercial plan of healing for money un-
der the guise of religion. Mr. King himself fears
something of this kind, although more consider-
ately stated ; as a possibility of bringing disap-
pointments to many when they discover their dis-
eases are not cured. We would much prefer to
agree with Mr. King, but there are so many in-
consistent statements in Mrs. McPherson’s inter-
view that we cannot wholly avoid the impression
that the power of wonderful healing appeals to
her more than reforming the church and the min-
istry. She has not, as yet, reached the point that
doctors are unnecessary, or that all cases of dis-
ease can be cured by her prayers, but she has very
nearly reached that point.
The near coming of Christ, we do not feel com-
jietent to discuss, nor do we feel better able to
discuss the spiritual value of her preaching or
teaching ; this is the field for the Theologian, but
this traff icing in human ills for which the church
is not responsible, has always thrown discredit on
religion. Just at this time, Christian churches
are carrying all they can bear without giving en-
couragement to healing fakers of the religious
sort. We should regret most deeply, if a danger-
ous competitor should come in to dispute the
field of healing with the Christian scientists.
It is gratifying to observe the conservative at-
titude of the Congregationalist in its editorial
comments. The editor realizes the effect of the
dramatic preaching of Mrs. McPherson on the
untrained minds of an uncritical public. He
realizes the disappointments certain to flow from
uncured, or only temporarily cured sick persons,
and the criticisms that are certain to fall on
Christian churches for claims of miraculous cures
often for a money consideration. We should not
condemn the church for these unfortunate oc-
currences, but the individual who seeks to benefit
from these claims, or pity the unfortunate ones
suffering from some mental defect.
THE PEKIN MEDICAL COLLEGE
Whatever may be our views of the religious
teachings of missionaries among the so-called
heathen, of one fact we are quite certain, the
value of education and the betterment of the
moral and physical condition of the people the
missionaries go among. The moral and physical
improvement of backward peoples are so closely
related to medicine, that we are justified in
holding that the medical equipment of a mission
is of fundamental importance. Devoted medical
practitioners have followed missionaries every-
where and, we cannot place too high an estimate
on the value of their work.
The Far East has been, and is a great field for
judicious missionary operation. The people of
these vast countries may be doubtful of their
religious activities, but of the cure of disease and
the relief of suffering they have no doubt. We
have nothing to offer Japan or its dependencies,
but in China and neighboring countries the case
is quite different. The few missionary doctors
are but a very small drop in the bucket. Far
seeing observers realized that important results
could be reached only by educating Chinese doc-
tors. Through the work of Cooperative Christian
112
Journal of Iowa State Medical Society
[March, 1922
Endeavor, the Pekin Union IMedical College has
been founded which expresses the last word in
medical college equipment. The story is an inter-
esting one. In 1901 Dr. Cochrane, a young Scot-
tish physician, organized a small hospital belong-
ing to the London ^Missionary Society. The Con-
gregationalist tells us how it happened. The hos-
pital had been destroyed by the Boxer Siege, “One
of Dowager’s leading statesman fell ill. One
Chinese doctor after another was called only to
fail. In this extremity the Empress had the for-
eign doctor called in with the result that the
statesman was cured. On account of his success
Dr. Cochrane was permitted to unfold to the Em-
press his plans for training Chinese physicians.
She not only expressed her approval, but gave
large sums for carrying out his proposals.”
This was the beginning of the Pekin Union
iMedical College which has received substantial
aid from many sources. Harvard University has
contributed much in various ways, and so has the
Rockefeller Foundation. About $5,000,000 has
been contributed for the construction of buildings
and equipment. From 1906 to 1915 British and
x\merican missionary organizations co-operated
in the development and maintenance of the col-
lege and later other agencies have aided. In
September a group of educators visited Pekin for
the purpose of dedicating this great humanitar-
ian enterprise. Among them J. D. Rockefeller, Jr.,
Mr. George E. \’incent. President of the Rocke-
feller Foundation, Dr. \Vm. Welch, and many
others.
The British and American missionary associa-
tions are entitled to great credit for the eaxly work
in organizing this important medical college, but
it is the Harvard and Rockefeller aids and di-
rection that has placed the college on a broad
foundation with an equipment that will place the
institution in the first rank of medical schools.
MATERNITY BILL
In the February Journal, we published the Ma-
ternity Bill recently passed by Congress, received
through the courtesy of Senator Kenyon. We
have read this bill carefully but confess to the
fact that we do not understand its meaning or
application. That it has merit, we do not doubt,
but wherein? The important need is of measures
that will decrease maternity death rate, that will
provide better care for mother and child during
a trying period.
The fundamental need is hospital care during
confinement and immediately thereafter. The
well-to-do are in serious danger, but the poor in
their unfortunate environment are in greater dan-
ger. Not only do these need immediate profes-
sional care but they also need education and di-
rection for their own welfare, and for the wel-
fare of the infant. The medical practitioner
knows full well that there is a period before con-
finement that dangerous complications may arise
that may be fatal to both mother and child, that
could be remedied by proper treatment under fav-
orable circumstances.
It is unquestionably true that general mater-
nity, and child welfare measures are of great im-
portance in the hands of lay welfare committees
and commissions, but there are features of the
case which can only be properly considered by
members of the medical profession. If there are
features in the bill that will permit the use of
funds for maternity hospital service for the dis-
tinct purpose of lessening the mortality rate, we
have no objections to offer even if the adminis-
tration of the law be in the hands of self-consti-
tuted boards.
A NEW HOSPITAL AT CAMP DODGE
We are publishing in this number a letter re-
ceived from Lieut.-Col. W. S. Conkling advocat-
ing the building of a memorial hospital at Camp
Dodge for the care of National Guard Soldiers
who may be injured or sick while on duty in the
service of the state or nation. There is no suit-
able means of care for the men to whom we owe
an obligation which can be adequately com-
pensated in money. It is true that there are good
hospitals in Des IMoines, but those who are fa-
miliar with industrial accidents or with military'
service know there is serious risk in transporting
badly injured persons even the distance of twelve
or fifteen miles. Not only is there a risk in trans-
portation, but the delay involves a greater risk.
There is a feeling that our soldiers arc entitled
to the best we can give them at all times. Also
considerations of welfare have an immense in-
fluence on the morale of men who voluntarily
give their time and service to the state. The
building of such a hospital would be a graceful
tribute to the men who offer their lives to our
country in time of need. The expressions em-
bodied in the resolutions should receive serious
and prompt consideration.
Dear Doctor Fairchild;
As you probably have noticed by the Press, the
National Guard officers had a meeting in Des Moines
last Thursday, Friday and Saturday and at the close
of this meeting each of the regiments and the medi-
cal department got together for a conference. At the
^^OL. XII, No. 3 1
Journal of Iowa State Medical Society
113
conference of the medical officers I submitted to
them the plans for a new hospital at Camp Dodge
which is needed very badly. Last year we used the
old dental building which did fairly well but, of
course, is not of a permanent character. The hospital
saved at least one life when a young man wa.s
brought in with a depressed fracture of the skull ap-
parently dying. Dr. V. A. Ruth promptly relieved
the depression and the young man is getting well al-
though he has had a very stormy convalescence. The
thought occurred to us while we were discussing this
hospital that it would be a fine idea to erect a me-
morial hospital and the following resolutions w*ere
passed:
“Resolved that steps be taken for the building of a
^Memorial Hospital at Camp Dodge, requesting the
support of the Iowa State Aledical Society, Iowa
State Dental Association, Iowa Branch National Red
Cross, Nurses Association, civic bodies in communi-
ties supporting National Guard Organizations, and
public spirited citizens. This memorial for doctors,
dentists, nurses and enlisted men of the ^ledical De-
partment from Iowa who lost their lives in the World
War.
These resolutions were submitted to the other Na-
tional Guard officers who received them enthusiasti-
cally. It should be possible to erect a memorial hos-
pital at Camp Dodge which will be of great benefit
to the state and a memorial for the medical men and
women who gave up their lives during the World
War.”
WILBUR S. CONKLING,
A. A. Surg. U.S.P.H.S.
The State University is erecting at the present time
a building, adjacent to the' University Hospital,
which is to be used entirely as a venereal hospital.
It is a two-story frame building and will be very light
and well ventilated; the first floor will be used for
men and the second floor for women and children,
and will accommodate about fifty or sixty patients.
Adult patients can be sent to this hospital under the
Haskell-Klaus Act, Chapter 78, Acts of the 38th Gen-
eral Assembly and children may be sent under the
Perkins Law, Chapter 24, Acts of the 36th General
Assembly.
It is my judgment that there has been nothing in
the State of Iowa which will do as much for the
Control of Venereal Diseases as the establishment
of this hospital by the University. Dr. N. G. Alcock
will have full charge of this hospital.
WILBUR S. CONKLING,
A. A. Surg. U.S.P.H.S.
The hospital above referred to is the result of
the efforts of President Jessup and Dr. Dean,
who have a bro?d vision of the needs of the state
and particularly of the needs of unfortunate indi-
viduals. Since the inception of the administra-
tion of the two officials above referred to the
University has been alive to progressive w^elfare
activities which places our great institution in the
front rank of educational, humanitarian and pub-
lic welfare organizations.
THE TRAINING OF NURSES
The 'Journal of Oklahoma State IMedical So-
ciety, speaking editorially of the training of
nurses holds that a three years’ training as a
routine requirement is unnecessary.
There is no good reason why an intelligent woman
should be required to give three years of her time
in order to master the fundamentals necessary to
carry out the orders of the attending physician.
There is much sentiment of this kind among
members of the medical profession. This senti-
ment no doubt grows out of the fact of the short-
age of nurses who are competent to perform the
ordinary duties of caring for patients suffering
from general diseases under the direct care of
physicians, and on account of the high fees
charged which are beyond the reach of a great
number of patients. If arrangements could be
made which would provide for a one or two
years’ course of training for intelligent young
women and a three years’ course for those who
desire to prepare themselves for special work,
after securing a high school course of prelimin-
ary preparation, the public would be much better
served than now with a standard three years’
course and a large portion of the sick without
nurses.
HOSPITAL STANDARDIZATION
The important work of the American College
of Surgeons in improving the standards of hospi-
tals in the United States and Canada should be a
matter of general professional information. At
the Philadelphia Conference October 24, the sub-
ject was fully discussed. Through the courtesy
of the director-general of the college, we have
been furnished with page proofs of the steno-
graphic notes which we will publish in install-
ments.
AMERICAN COLLEGE OF SURGEONS
Report of the hospital conference held at the
clinical congress of the American College of Sur-
geons, October 24, 1921, Philadelphia, ilorning ses-
sion— The President, George E. Armstrong, M;D.,
presiding.
114
Journal of Iowa State Medical Society
HOSPITAL STANDARDIZATION, ITS INCEP-
TION, DEVELOPMENT, AND PROGRESS
IN FIVE YEARS
\ ou have all undoubtedly asked yourselves why
this program of the American College of Surgeons
has been received with so much approval, why it has
attracted so much attention, why it has had so much
influence.
Scientific medicine is developing so rapidly that of
necessity it is reducing the number of the medical
profession in proportion to the people they have to
care for. Medicine, therefore, is becoming more
wholesale and institutional, less retail and domicil-
iary. That of necessity has placed an enormous re-
sponsibility upon the hospital, because the hospitals
must be the institutions in which the wholesale or
group medicine is practiced.
The American College of Surgeons is responsible
for the standardization of hospitals, because in its
early days it found it necessary to standardize its
own environments. For instance, in making a stand-
ard for admission to fellowship, it was necessary that
we ask the candidates to furnish us the reports of
fifty major operations and fifty minor operations, in
lieu of an examination. These reports began to come
in. They were on all kinds of forms. There was ab-
solutely no standard record on which they could give
us the evidence of their own ability to practice sur-
gery. Soon we were asked from every direction to
furnish a standardized system of records, to suggest
a form upon which these records could be given to
the college. We attempted to do that. A committee
was formed for the purpose, and we furnished, wher-
ever required, a set of standardized records. Then
what happened? The hospitals — a great many of
them — began to ask us if we could not in some way
furnish these same standardized records or forms to
them, which, of course, we were very glad to do.
That was the first step in the standardization of
hospitals. Then, early during the war, it became
necessary for us to have some other minimum stand-
ards that would apply to the hospitals in the camps,
the army hospitals. And in Washington was called a
conference of medical officers and we discussed a
minimum standard for military hospitals.
After that, in one year, the American College of
Surgeons formulated its minimum standard for hos-
pitals. Is there anything that a hospital can leave
out of that standard and be a hospital? First,
records; second, staffs, with staff meetings; third,
a competent and honest staff; fourth, laboratories.
That is practically the minimum standard of the
American College of Surgeons. Any hospital that
cannot furnish this minimum standard is not a hos-
pital. It is the very minimum thing we could ask of
hospitals to do in order to have us recognize them
as hospitals.
That led immediately to a survey of the hospitals
to ascertain which hospitals met this minimum stand-
ard. For the last three or four years surveyors em-
ployed by the college have visited all of the hospitals
[]\Iarch, 1922
of one hundred or more beds in the United States
and Canada.
Summary of Yearly Reports
In 1918, of the 692 general hospitals of one hun-
dred or more beds, in the United States and Canada,
89 met the standard; in 1919, 198; in 1920, 407, or 57
per cent; and this year, 568, of a total of 761 hospi-
tals, or 74 per cent, meet the standard of the college.
1921 Report
Today, we have the pleasure of presenting to you
our annual report on the hospitals of North America,
having one hundred or more beds. This list contains
the names of such general hospitals in the United
States and Canada as have met the minimum stand-
ard. In this list, a certain number of institutions
are designated with a star. This group includes those
hospitals which, when visited, had adopted the funda-
mental principles of the minimum standard, but
which at that time had not had sufficient oppor-
tunit}' to develop all of them to a degree meriting the
fullest approval. The hospitals listed without a star
instituted these measures at an earlier date, and con-
sequently received the benefits of a longer experi-
ence in the workings of the program and a broader
conception of its application.
The Future Program
The program of the future will be extended to in-
clude all general hospitals of fifty or more beds in
the United States and Canada. Of these institutions,
many of which have been visited, a large number
showed a working knowledge of the minimum stand-
ard and evinced an active desire to cooperate. The
percentage of these meeting the standard on first
visit compares favorably with the percentage of the
larger hospitals approved on first inspection. If
proof were needed of the universal application of
the minimum standard, the acceptance by the smaller
hospitals would furnish it. Stressing only broad
fundamentals, the minimum standard molds itself to
meet specific needs, nowhere impeding initiative or
fettering judgment. Rightly conceived and carried
out, it makes the hospital the proved guardian of the
community health, rendering scientific service to all.
Why the College Must Continue This Survey
Now, surgeons and hospital superintendents, what
is the future program of hospital surveys other than
I have indicated here? Why should the Am.erican
College of Surgeons continue this work? It should
continue the work because it is the measure that the
college has of the fitness of the men who we expect
will enter the college. It is impossible for the college
to do anything but to take the leadership in the ques-
tion of its own standard. It is something that we
cannot delegate to someone else. Therefore, as long^
as the American College of Surgeons is in existence,
I can see that it will be the duty of the American
College of Surgeons — duty to itself — to see that the
environment in which its candidates do their work is
of the proper kind. Therefore, this work will have
VoL. XII, No. 3]
Journal of Iowa State Medical Society
115
to go with the college. The success of this work, I
believe you will all realize, lies in the fact that back
of it is a great ideal for service and honesty. And
this is the reason the program has succeeded far be-
yond our expectations. — Franklin H. Martin, M.D.,
Chicago, Director-General of the American College
of Surgeons.
HOSPITAL STANDARDIZATION FROM THE
VIEWPOINT OF THE MEDICAL PRO-
FESSION
Mild as this meeting looks, Mr. Chairman, it rep-
resents a revolution that has come very quickly and
very sanely. Years ago Dr. Codman asked of the
medical profession and of hospitals: “Do you dare
show us your end-results?” A Dr. Martin takes up
this challenge and with a Bowman and a Moulinier
puts it into effect, and in working order, on a surgi-
cally sane basis. Hospitals have been answering that
challenge ever since and their answer to the chal-
lenge represents the effect of hospital standardiza-
tion.
Hospital standardization might belong to the
American Hospital Association, that wonderfully
able body represented here so fully. But standardi-
zation of the surgeon belongs to the surgeon.
Now, Codman saw years ago that you can have a
surgical accounting as you can have any accounting.
If it could be done in government, if it could be done
in finance, it can be done here. Honor, honesty, and
efficiency can be measured.
Let us come to the staff review. I take it the col-
lege— I am not speaking_ officially for them — I take
it the college has had this to say: “Yes, we can
give you a sample laboratory list, but as to what
constitutes a staff review, you had better experiment
a while yourselves. Start the machinery. Try it
out.” I think the time has come for the college to
give us a sample procedure for staff meetings, adapt-
able to different types of hospitals.
One other pitfall: Here is a surgeon knowing that
he should not have a mortality in his active service,
we will say, of more than 4 per cent, and who there-
fore refuses to endanger his mortality record by
certain operations. I do not want any man to re-
fuse to open my abdomen because he might exceed
his death-rate. You have to have fearless surgery
today.
Now, on the other hand, the reckless experimenter
with human life must be curbed. Some of the great-
est surgeons are the most reckless. How are we go-
ing to take counsel in any of these great things un-
less we do as Codman has told us to do? We should
charge up an error of judgment or of technique when
indicated and, in other cases, wipe that physician’s
record clean from censure who operates upon a pa-
tient in extremis, hoping to save a life. In other
words, this matter of fair surgical mortality must be
formulated and I think the college is the authority
to act.
The hospital trustee comes to me and says: “You
know my interest in this matter. What should our
records be? What is a fair mortality? What is a
fair infection in clean cases?” The college has given
us certain averages. What would be a normal aver-
age? This is another place where the college might
compile and publish interesting suggestions. In my
opinion, the time has come to define a few other
minimum standards.
Another point regarding the staff meeting: It
should be for mutual stimulation and encouragement.
Nothing is gained by turning it into a fault-finding
clinic. We must bring in individual triumphs, as
well as failures. Then the staff meeting will make
for better effort.
When all is said and done, gentlemen, the whole
story comes down to this: You cannot legislate
these things. As the last speaker has said, the an-
swer to all progress in medicine depends upon the
elimination of the unfit, and the development of
individual honor and competence. — Robert L. Dickin-
son, M.D., New York.
IOWA UNIVERSITY NEWS NOTES
Don M. Griswold, M.D.
Dr. A. H. Byfield gave an address before the
Creighton Medical staff in Omaha on “The Clinical
Manifestations of Focal Infections in Children,” Jan-
uary 19, 1922. Dr. A. H. Byfield is to give a talk in
Des Moines early in February on “Tuberculosis in
Infants and Children.”
Dr. Charles Rowan who has been acutely ill for
the past three weeks with rheumatism, will make a
Mediterranean trip, starting Monday, January 30,
1922, and will be gone three months returning about
the 1st of May.
The new home for nurses across the river was
opened for occupancy the 1st of January, 1922, and
the new cafeteria was started on January 24, 1922.
This cafeteria is equipped with the latest improve-
ments, and will easily seat about 100 at a time.
Iowa University’s annual medical clinic is an-
nounced for April 11 and 12 at the University Hos-
pital, under the direction of the faculty of the col-
lege of medicine. This is for all doctors interested
and is not confined to alumni of the University.
Most of the work will be presented by members of
the faculty.
Miss Mary C. Haarer has resigned her position as
superintendent of nurses at the University Hospital.
Miss Haarer has held this position for more than
five years and it is through her ability and progres-
sive ideas of nursing, that this school has been placed
among the foremost of the country today. During
her tenure of office, she was faced with the trying
conditions of the war period, after which the epi-
demic of influenza raged, and it was during these
116
Journal of Iowa State Medical Society
[March, 1922
periods that her wonderful ability for organization
stood out very prominently, and her leadership was a
most valuable asset to the school and community.
Her high ideals and principles of nursing, which she
has instilled into her various classes of students, will
long be felt as an influence throughout the nursing
world. It is with sincere regret that we lose Miss
Haarer from the University of Iowa, and wdsh her
success in her future work, wherever it may be.
MEDICAL NEWS NOTES
A resolution protesting against the plan by which
congress would replace medical reserve officers with
civilian doctors was passed January 5 by former ser-
vice men who are confined in the government re-
construction hospital at Colfax, Iowa.
The resolution, bearing the signatures of ninety-
one disabled soldiers, will be forwarded to President
Harding immediately.
The former service men are opposed to any change
in the staff of the Colfax institution on the grounds
that the reserve officers are familiar with their dis-
abilities and show more interest in the general wel-
fare of the patients than civilian doctors, according
to one of the hospital officials.
It is said that the attempt to change the physi-
cians of government hospitals is the work of a group
of politicians in congress who are opposed to the
Dyer-Watson bill, under which reserve officers were
to have been placed on the staffs of the hospitals
for a specified period.
Under the present arrangement physicians at the
Colfax hospital and other government institutions
are being subjected to an injustice in the opinion of
members of the medical staff at the Colfax recon-
struction hospital as they have no assurance that
their connections will be permanent.
“We have no future under the present arrange-
ment. We don’t know from one day to the next
whether we will have a position or not,’’ said one
physician, a member of the medical reserve corps.
The former service men, at their meeting yester-
day, also passed a resolution declaring that in their
opinion the government would be subjected to an
added expense if any change to civilian doctors were
made.
The movement to replace the reserve officers by
civilians has been held up temporarily by congress.
Representatives Ramseyer and Sweet of Iowa con-
ferred with the veterans bureau in Washington yes-
terday, opposing the change. The American Legion
is also protesting against the change.
GROUP PRACTICE
The Medical Record for March 19, 1920, contains
an editorial which presents certain arguments in
favor of group practice. Group practice according
to the Record offers the best solution for the young
men just entering the field of medical practice, and
concludes; “Granting the ability of the group to get
along amicably together, to arrange finances satis-
factorily, to behave generously toward other groups
or individuals, to refrain from charging exorbitantly,
etc., group practice is in a fair way to become an
excellent medium through which the public may
profit by the recent hospital graduate and occupy a
position of financial solvency at no cost to his self-
respect.’’
FUNDS FOR MEDICAL COLLEGE
It is reported that the Albany Medical College has
succeeded in raising $120,000 — $40,000 a year for the
three years — which was necessary to secure a gift of
$60,000 — $20,000 a year for three years — from the
Rockefeller Foundation. This assures the college an
additional income of $60,000 per year for the next
three years. — Journal of A. M. A.
MEMORIAL TO DR. SATO
In memory of the late Dr. Susumu Sato, who de-
voted his life to the progress of the medical science
in Japan, a laboratory will be constructed at a cost
of 300,000 yen, for the Yuntendo Hospital, the larg-
est private hospital in Japan. • Courses in every
branch of medical science will be offered under the
presidency of Dr. Susumu Nukada, and clinics will
also be held in the institution. — Journal of A. M. A.
PUBLIC HEALTH SERVICE BUREAU
CIRCULAR NO. 323
To: Medical Officers in Charge, U. S. Public
Health Service, and others concerned:
Subject: Change in designation of U. S. Public
Health Service Hospitals.
1. You are advised that hereafter the word “Ma-
rine” will be substituted for the words “Public
Health Service” in the names of the following sta-
tions: U. S. Public Health Service Hospital No. 29,
Sewell’s Point, Norfolk, Virginia; U. S. Public Health
Service Hospital No. 43, Ellis Island, N. Y. ; U. S.
Public Health Service Hospital No. 66, Carville,
Louisiana; U. S. Public Health Service Hospital No.
70, 67 Hudson Street, New York, N. Y.
The above named stations shall hereafter be desig-
nated as follows: U. S. Marine Hospital No. 29,
Norfolk, Virginia; U. S. Marine Hospital No. 43,
Ellis Island, N. Y.; U. S. Alarine Hospital No. 66,
Carville, Louisiana; U. S. Marine Hospital No. 70,
New York, N. Y.
2. Substitute the words “U. S. Veterans’” for the
words “U. S. Public Health Service” in the designa-
tion of all other U. S. Public Health Service hospi-
tals operating under the designation “U. S. Public
Health Service Hospital,” and all others of the same
designation hereafter re-opened. All of the hospitals
stipulated in this paragraph and hospitals subse-
quently acquired by purchase, lease or otherwise, by
VoL. XII, No. 31
Journal of Iowa State Medical Society
117
the Public Health Service, excepting such as shall be
acquired and operated as U. S. Marine Hospitals, will
hereafter, until these instructions are amended or
rescinded, be known as U. S. Veterans’ Hospitals.
3. It should be noted that the numbers of the
U. S. Public Health Service Hospitals are not to be
changed, and consecutive numbering will be con-
tinued.
4. The foregoing plan does not apply to the U. S.
Marine Hospitals and no change is to be made in the
twenty-three marine hospitals of the U. S. Public
Health Service. The hospitals operated by the Pub-
lic Health Service are divided into two classes; viz.,
U. S. Marine Hospitals and U. S. Veterans’ Hospitals.
5. You are directed to inform all officers and
employes at your station of the changes outlined in
this letter, and instruct them to govern themselves
accordingly.
H. S. GUMMING,
Surgeon General.
SOCIETY PROCEEDINGS
Clinton County Medical Society
The Clinton County Medical Society met at the
Lafayette Hotel, Clinton, Iowa, on Thursday eve
ning, January 26, 1922, with an attendance of over
thirty members.
After dinner in the dining room, adjournment was
taken to the hotel parlors, where after a business
session, the following program was presented:
Blood Transfusion in Anaemia, by Dr. H. A. White
of Clinton. This subject was presented in most ex-
cellent form, showing much thought and study in its
preparation, and was freely discussed by Doctors
Heusinkveld and Hoffstetter, with closing remarks
by Doctor White.
Dr. C. Ross, pathologist at Jane Lamb Memorial
Hospital, Clinton, then reported a rare case of
Carcinoma of the Lung, illustrated by radiograms,
taken by Dr. B. C. Knudsen, radiologist of the above
hospital. Dr. Ross’ report contained symptomat-
ology, clinical findings and physical examination, to-
gether with complete autopsy and laboratory report
of microscopic examination of stained specimens.
The paper was freely discussed by Doctors’ Morgan,
Sugg, Hullinger, White and Hohenschuh
Adjournment was then taken to meet the first
week in March.
M. S. Jordan, Sec’y-Treas.
Fremont County Medical Society
The Fremont County Medical Society met at the
Hamburg Hospital, Friday, January 6th, and elected
the following officers for the ensuing year; Dr.
Wm. Kerr, Randolph, president; Dr. R. C. Danley,
Hamburg, vice-president; Dr. A. E. Wanamaker,
Hamburg, secretary-treasurer; Dr. Ralph Lovelady,
Sidney, censor; Dr. E. E. Richards, Hamburg, dele-
gate to state meeting.
Greene County Medical Society
The annual meeting of the Greene County Medical
Society was held at the home of Dr. and Mrs. Ben
Hamilton, Jefferson, February 10, 1922. Guests of
the evening were Miss Greene, county nurse, and Dr.
Francis R. Holbrook of Des Moines. Dinner was
served for the physicians and their wives at 6:30 p. m.
This was prepared and served by the society. Miss
Greene gave a talk on Duties and Results of the
Public Welfare Nurse. The ladies then attended a
movie. Dr. Holbrook talked on Fractures and Their
Treatment Their Present Status. This was a very
instructive talk. Each physician then gave the his-
tory and treatment of a fracture case from his own
practice. Each case was discussed. Officers elected:
I resident. Dr. A. I. Reed of Grand Junction; vice-
president, Dr. G. Franklin of Jefferson; secretary-
treasurer, Dr. J. Black, Jefferson; censors, Drs.
Hamilton, Sr., Hoyt and Cressler; delegate. Dr. Ben
Hamilton; alternate. Dr. Geo. Franklin.
The following were present: Drs. Reed, Kester
and wives. Grand Junction; Dr. and Mrs. Cressler,
Churdan; Drs. Hoyt, Hamilton, Sr., Franklin, Black,
Hamilton, Jr., and wives of Jefferson. The past year
has been a pleasant and profitable one for the mem-
bers. Each meeting has been one for pleasure as
well as business. The physicians’ wives are very
much interested and provide eats and program for
each meeting.
Benj. C. Hamilton, Jr., Sec’y.
Hancock-Winnebago County Medical Society
Doctors Stull and Fillmore entertained the Han-
cock-Winnebago County Medical Society and invited
guests Monday afternoon and evening.
The scientific program began at three o’clock. The
first number was a paper on the treatment of heart
disease by Doctor Field of Fort Dodge. The second
a paper on the Diagnosis of Kidney Lesions by Dr.
Stam of Mason City. Following this a roast pig
was served.
Jasper County Medical Society
The Jasper County Medical Society held its last
meeting of the year Tuesday evening, December 6
at Prairie City.
The meeting was called to order by Dr. F. W.
Stewart, president of the society. After reading of
the minutes by the secretary. Dr. Peter Herney of
Prairie City, read a paper on Diphtheria and Its Con-
trol. This was an especially interesting subject be-
cause of the extensive epidemic of diphtheria in
Prairie City and vicinity.
Dr. Edward J. Harnagel of Des Moines was then
introduced, and read a very interesting paper on Re-
current Inguinal Hernia.
After a discussion by members of the profession,
election of officers for the year of 1922 took place.
The following were elected: Dr. J. Leo Taylor,
Monroe, president; Dr. C. R. Van Voorhis, Prairie
City, vice-president; Dr. W. E. Anspach, Colfax,
118
Journal of Iowa State Medical Society
[March, 1922
secr£tary and treasurer. There was a good attend-
ance of members of the society. The following Des
Moines men favored us with their presence: Drs.
Edward J. Harnagel, J. W. Martin and Verl Ruth.
W. E. Anspach, Sec’y.
Lee County Medical Society
Officers elected: Dr. I. W. Traverse, Ft. Madi-
son, president; Dr. I. M. Lapsley, Keokuk, vice-
president; Dr. Rankin, Keokuk, secretary-treasurer;
Dr. Frank Fuller, Keokuk, delegate to State Society.
Mahaska County Medical Society
The Mahaska County Medical Society met in Os-
kaloosa, December 21, 1921. Dr. C. E. Ruth of Des
Moines read a paper on Fractures.
Officers elected: Dr. Fred J. Jarvis, president;
Dr. John A. Ruan, vice-president; Dr. F. A. Gillette,
secretary-treasurer. The social feature of the meet-
ing was the annual banquet at the Chamber of Com-
merce attended by the members of the society and
their ladies.
Marshall County Medical Society
Forty members of the Marshall County Medical
Society were the guests of Dr. R. E. Keyser at din-
ner Thursday night, January 4 at the Chamber of
Commerce. The program of the monthly meeting
of the society; Dr. Lawrence E. Kelley, Des Moines,
read a paper on Treatment of Fibroid, followed by
discussions by Dr. M. U. Chesire and Dr. Thomas
Burchman, Des Moines and Dr. L. F. Talley.
After Treatment of Peritonitis was the subject of
a paper read by Dr. H. E. Pfeiffer, Cedar Rapids.
Discussions by Dr. Theodore Engle, State Center;
Dr. E. M. Meyers, Boone, and Dr. Keyser. Dr. Ed-
ward M. Meyers read a paper on Metastatic Arthritis.
Discussion by Dr. Pfeiffer and Dr. F. L. Wahrer.
Muscatine County Medical Society
Adoption of new policies relating to the enforce-
ment of health regulations in Muscatine county was
urged before the board of supervisors by the Musca-
tine County Medical Society.
Suggestions were presented by Dr. T. F. Beveridge
and Dr. B. E. Eversmeyer. Various members of the
medical society met in conference in which the sub-
ject of the county health physician was discussed.
According to the plan suggested to the super-
visors, the duties of the health physician would be
more specific than at present, in addition to making
that official’s task more representative. As pointed
out before the board by Drs. Beveridge and Evers-
meyer, the county health physician devotes most of
his official work to attending patients at the jail and
court house. The contention was raised that his
duties should be similar to those of the city health
officer, with full authority to placard homes on oc-
casions of epidemics and to supervise the health of
the county much as the city physician does locally.
Another suggestion offered by the representatives
of the medical society was the inauguration of a sys-
tem whereby health officers be appointed for various
townships of Muscatine county. This was explained
as meaning that a doctor in Muscatine, Wilton, West
Liberty, Nichols and perhaps one or two other towns
be designated as the health physician for adjacent
townships. These should be given all the power and
authority of a regularly appointed county health
physician.
It was emphasized that through this method, con-
siderable saving in transportation costs would result.
Under the present arrangement, if the county health
physician is called upon to attend a case in a distant
township, the expense to the county is proportion-
ately greater than if such a case were within a closer
radius to Muscatine.
Polk County Medical Society
The annual meeting of Polk County Medical So-
ciety was held at the Grant Club, December 27, 1921.
Including the ladies and invited guests, there were
approximately 300 present. The banquet was served
at 6:30 p. m.
Following the banquet, Harvey Ingram, editor of
the Des Moines Register delivered an address. Al-
truism in Nature, which was highly appreciated, par-
ticularly, because it related to question of vital im-
portance, not only to our own people, but to the en-
tire world. Following Mr. Ingram’s address was the
president’s address which related to matters of in-
terest to the society including the work of the past
year.
The total membership of the society at the end of
the year 1921 is 250.
Resolution was adopted by unanimous vote ap-
proving the appointment of Dr. Rodney P. Fagan
as secretary of the Iowa State Board of Health. Dr.
Fagan is a graduate from Drake University College
of Medicine, 1912. Interne, Mercy Hospital, served
in the World War first as surgeon; Second Iowa In-
fantry with rank of major; later was transferred to
109th Engineers and sent to France; was again trans-
ferred to the 34th Division as assistant division sur-
geon, and finally transferred to the 80th Division and
returned home with the Division as acting chief sur-
geon with the rank of lieut. -colonel.
The following officers were elected for 1922: Dr.
A. P. Stoner, president; Dr. M. L. Turner, vice-pres-
ident; Dr. H. E. Ransom, secretary; Dr. E. B. Moun-
tain, treasurer.
The following resolution was introduced by Dr.
Walter L. Bierring and adopted by the society:
“Whereas: The announcement has been made of
the appointment of'Dr. Rodney P. Fagan as secre-
tary of the Iowa State Board of Health and Medical
Examiners, and
“Whereas: We, the members of Polk County
Medical Society feel highly honored and gratified to
have this selection made from our membership, be it
VoL. XII, No. 3]
Journal of Iowa State Medical Society
119
“Resolved; That this society record herewith its
expressions of congratulation, and pledge of unquali-
fied support to Doctor Fagan in his great work to
promote the public health interests of our state.
“Be It Further Resolved, That a copy of these res-
olutions be sent to the governor and other members
of the appointing board, and to Dr. Fagan.
H. E. Ransom, Sec’y.
Story County Medical Society
The Story County Medical Society held its annual
meeting in Nevada Wednesday evening, January 11,
at the office of Dr. Bush Houston, president of the
society. Preceding the regular session which was
held at 8 o’clock in the evening, a special dinner
menu was served at the Olympia Cafe.
The evening program consisted of papers and dis-
cussions on medical topics. The formal papers were
Dr. F. S. Smith of Nevada, on Gall Bladder, and Dr.
Joor of Maxwell on Asthma. Doctors McKharin
and Henske of Iowa State College at Ames were
elected to membership in the society.
Officers were chosen for the year as follows:
President, E. B. Bush of Ames; vice-president. Dr.
Glann of Colo; secretary-treasurer, B. G. Dyer of
Ames.
The next meeting of the society will be held at
Ames.
Tama County Medical Society
Tama County Medical Society met at Tama, De-
cember 14, 1921. A combined social and professional
convention. Following a banquet served by the
ladies of the Baptist church. Dr. Thompson (mayor)
delivered an gddress. Dr. McDowell read a paper ori
The Treatment of Pneumonia. Dr. Allen read a
paper on The Treatment of Ordinary Surgical Cases,
illustrated by clinical patients.
Members present: Drs. Pinkerton and Crabb of
Traer; Drs. Guesner and Brandt of Dysant; Dr. Mc-
Dowell of Gladbrook; Dr. Hasek of Clutive; Drs.
Thompson, Allen, Sievers, Whalen and Carpenter,
including their wives; Miss Ebersole, Miss Cher-
venka, Mr. and Mrs. Earl Spooner, Mr. and Mrs.
L. E. Roack and Mrs. Leonard Allen as guests.
The community and social relationship of county
medical societies is a most encouraging feature of
medical organization.
Washington County Medical Society
Washington County Medical Society held its an-
nual meeting at Washington, December 19.
The address of the evening was by Paul A. White
of Davenport on Radium.
Officers elected: President, Dr. C. W. Stewart,
Washington; vice-president. Dr. N. J. Lease, Craw-
fordsville; secretary and treasurer. Dr. H. C. Hull,
Washington; delegate to State Medical Society, Dr.
C. A. Boice, Washington.
Keokuk Physicians’ Club
Keokuk Physicians’ Club met December 14, 1921.
Dr. Tom B. Throckmorton of Des Moines delivered
an address on the Diagnosis of Nervous Diseases.
Officers elected: President, Dr. O. T. Clark; vice-
president, Dr. W. M. Hogle; secretary. Dr. F. J.
Chapman; treasurer, Dr. C. A. Dimond; censors, Drs.
William Rankin, W. M. Hogle, and E. G. Wollen-
weber.
Waterloo City Medical Society
The Waterloo City Medical Society recently
“pulled off” what is believed to have been one of the
most successful and largely attended medical meet-
ings ever sponsored by any local society in the state.
Prior to the date of the meeting which occurred
January 21 the society sent out a large number of in-
vitations and approximately 150 responded; this at-
tendance, added to that of the members of the local
profession made an imposing audience. The pro-
gram began with a complimentary dinner tender by
the society to those present which took place in the
dining rooms of the Greater Waterloo Association
at which nearly 200 physicians sat down.
At the conclusion of the dinner the president of
our society, Dr. T. F. Thornton in a few well chosen
words, introduced the ' headliners of the program —
the essayist being Dr. George W. Crile of Cleveland
who addressed the meeting on Some Points in Sur-
gery of the Stomach, the discussion of which was
opened by Dr. J. E. Summers of Omaha. Both of
these men and their abilities are so well known that
it is only necessary to mention their names to con-
vey an impression of the close attention which was
given to their utterances. Following Dr. Summers a
general discussion was indulged in by many of those
present, after which Df. Crile closed in a highly in-
teresting and very profitable manner to those pres-
ent. After adjournment an informal reception in the
club rooms was held to the guests of honor. Many
notable Iowa physicians were present, some of them
from considerable distances. It is the policy of the
Waterloo society to hold similar meetings at monthly
intervals during the active season^and it is the hope
of its officers that this meeting is an index of the
character of those to follow.
F. W. Porterfield.
Mississippi Valley Medical Association
Officers elected: President, Dr. Charles E. Bar-
nett, Fort Wayne, Indiana; first vice-president. Dr.
William Engelbach, St. Louis, Missouri; second vice-
president, Dr. John de J. Pemberton, Rochester,
Minnesota; secretary. Dr. Henry Enos Tuley, Ken-
tucky, re-elected; treasurer, Dr. Samuel C. Stanton,
Chicago, Illinois, re-elected. Place of meeting,
Rochester, Minnesota.
— The Chicago Medical Recorder.
120
Journal of Iowa State Medical Society
[March, 1922
TUBERCULOSIS CLINIC
All physicians in attendance at the annual meeting
of the Iowa State Medical Society will be interested
in a tuberculosis clinic to be held in conjunction
therewith on the afternoon of Friday, Alay 12, under
the auspices of the Iowa Trudeau Society which is
affiliated with the Iowa Tuberculosis Association.
Arrangements have been made to bring to Des
Moines for this occasion George Thomas Palmer,
M.D., of Springfield, Illinois, well known tuberculo-
sis specialist, and president of the Illinois Tuberculo"
sis Association.
THE ST. LOUIS MEETING OF THE AMERI-
CAN MEDICAL ASSOCIATION
The May meeting of the American Medical Asso-
ciation at St. Louis promises well toward being the
largest in attendance of any of the association’s ses-
sions. Since the publication of the hotels in the
Journal of the Association in December, inquiries
and reservations are being made daily. The hotels
and the Conventions Bureau are aiding the commit-
tee in a most satisfactory and helpful way to see that
the Fellows are comfortably housed and accommo-
dated. The A. !M. A. meetings tax all cities enter-
taining them to the limit of hotel capacity. When-
ever possible a good Fellow should double up so that
no one is left without comfortable lodging.
Reservations should be made by communicating
direct with the hotels. If satisfactory arrangements
cannot be made in this way, write to Doctor Louis
H. Behrens, chairman committee on hotels, 3525 Pine
street, St. Louis, Missouri.
St. Louis’ Leading Hotels
American, Seventh and Market streets — Diseases
of Children.
American Annex, Sixth and Market streets — Path-
ology and Physiology, Pharmacology and Thera-
peutics.
Beers, Grand and Olive streets.
Brevort, Fourth and Pine streets.
Cabanne, 5545 Cabanne street.
Claridge, Eighteen and Locust streets — Obstetrics,
Gynecology and Abdominal Surgery.
Hamilton, Hamilton and Maple streets.
Jefferson, Twelfth and Locust streets — Surgery,
General and Abdominal, Orthopedic Surgery.
Laclede Hotel, Sixth and Chestnut streets.
Majestic, Eleventh and Pine streets — Dermatology
and Syphilology, Nervous and Mental Diseases.
Marion Roe, Broadway and Pine streets.
Marquette, Eighteenth and Washington streets —
Laryngology, Otology and Rhinology.
Maryland, Ninth and Pine streets — Gastro-Enter-
ology and Proctology, Urology.
Planters — Fourth and Pine streets — Ophthalmol-
ogy.
Plaza, 3300 Olive street.
Roselle, 4137 Lindell Boulevard.
St. Francis, Sixth and Chestnut streets.
Statler, Ninth and Washington streets — Practice
of Medicine.
Stratford, Eighth and Pine streets.
Terminal, Union Station.
Warwick, Fifteenth and Locust streets — Stomat-
ology, Preventive Medicine and Public Health.
Westgate, Kingshighway and Delmar streets.
HOSPITAL NEWS
Iowa University’s new $275,000 psychopathic hos-
pital is now open and patients are being attracted
from all parts of the state and from adjacent states.
The institution is one of four such institutions in the
country, others being established at Baltimore, Bos-
ton and Ann Arbor. The Ann Arbor hospital and
the one here are the only two that are directly con-
nected with university medical schools.
The hospital was built primarily to treat patients
from Iowa financially unable to receive treatment in
private institutions, but patients from outside the
state and also from within the state whose finances
are sufficient to pay well for treatment are also
coming here, lured by the exceptional facilities and
extremely competent staff.
A total staff of twenty-seven will be maintained.
At present this staff is only partially complete and
consists of Dr. S. T. Orton, director. Dr. T. G.
Lowrey, assistant director, J. B. Morgan, psycholo-
gists, O. L. Hoover, chemist. Miss Margaret Moffet,
social worker, and Dr. G. S. Sprague, senior interne.
A junior interne is soon to be appointed. The re-
mainder of the personnel is made up of nurses and
attendants.
The hospital here is the best adapted in the coun-
try for treatment of mental cases, and though it is
limited to sixty patients at a time, it is sure to do a
great work.
Citizens of Manning are planning the erection this
spring of a new hospital to be under the management
of Catholic Sisters. The new building will have a
capacity of from thirty-five to fifty beds and will
cost not less than $30,000, according to preliminary
estimates.
PERSONAL MENTION
Appointments of Union county health physicians
for the year 1922 were made as follows: Dr. F. W.
Loomis, Shannon City; Dr. M. B. Reed, Cromwell;
Drs. E. C. Ayres and Dr. Lamb, Lorimor; Dr. H. M.
Stanley, Creston; Dr. C. C. Rambo, Kent; Dr. J. W.
Lauder and Dr. C. B. Roe, Afton.
Doctors Kenefick and Hartman have formed a
partnership and together will conduct the Algona
Hospital. For several years they have cooperated
in their work and now they will be known by the
VoL. XII, No. 31
Journal of Iowa State Medical Society
121
firm name, Kenefick & Hartman with offices at the
hospital.
The supreme court of the United States January
16, 1922, denied the petition for certiorari to review
the case of Dr. Walter Matthey of Davenport, con
victed under the espionage act. This ends the possi-
bility of appeal to the supreme court of the United
States. The court did not deliver an opinion, but
simply denied the petition for review which was filed
a week ago.
The conviction of Walter Matthey in the federal
court at Davenport, Iowa, on the charge of having
aided another to violate the espionage act will stand,
the supreme court January 16, 1922, refusing to re-
view the case. The conviction was based on a public
speech made by Daniel H. Wallace at Davenport, in
which he is alleged to have urged those inducted into
the military service to refuse to serve abroad, and
those who had not to resist the draft and refuse to
enlist. Matthey was charged with having “aided and
induced” Wallace to make the speech. He contended
that the indictment upon which he was convicted was
defective and did not charge him with a distinct of-
fense in violation of any law. (This action by the
court means that the conviction in the lower court
and the sentence to a year and a day in the federal
penitentiary stands so far as courts are concerned.
It is e.xpected a petition for clemency may be pre-
sented to the president on behalf of Dr. Matthey.) —
Davenport Times.
Dr. D. S. Bradford of Janesville, Iowa, celebrated
his eighty-first birthday, December 4. Dr. Bradford
has practiced medicine in Janesville over fifty-five
years.
Dr. Ray Wycoff of Wapello has been appointed
surgeon in charge of the Ryder Memorial Hospital
at Porto Rico.
Minnesota Medicine publishes in the May number
a memorial to Dr. Arthur Gillette of the University
of Minnesota. The reputation which Dr. Gillette
had acquired in the department of orthopedic sur-
gery had become nation wide. Not alone for the
distinguished value of the work he had done but also
for the activity he displayed in presenting the best
of orthopedic surgery to the profession. In 1886 Dr.
Gillette graduated from the St. Paul Medical College.
In 1895 he began teaching as instructor in orthopedic
surgery; in 1897 as clinical professor and in 1898 he
was advanced to full professor. In 1913, he was
made head of the division of orthopedics. Dr. Gil-
lette’s death will be felt as a serious loss in that
state of many distinguished medical men.
Mrs. Lela Bowman, wife of Dr. F. A. Bowman,
Leon, died February 7 from post diphtheritic pa-
ralysis.
Dr. and Mrs. E. E. Krider of Oelwein, Iowa, re-
turned recently after spending the past two months
in California and various places of interest enroute.
OBITUARY
Dr. B. F. Shreve of Bloomfield died at his home
from apoplexy, December 19, 1921.
Dr. Shreve was born in Perry county, Ohio, Feb-
ruary 20, 1841 where he received a common school
education. In 1860 he moved to Douglas county,
Illinois and taught school. In 1862 he enlisted in
Company B, 79th Illinois Infantry. Was taken pri-
soner at Stone River and sent to Richmond, \'isginia,
for thirty-one days and paroled. In March, 1863, he
was sent to Benton Barracks, exchanged, and was
transferred to the Veterans Reserve Corps; ap-
pointed an army surgeon, and stationed at Indian-
apolis until mustered out of the service in July, 1865.
Returning to civil life, he first returned to Illinois
and a year later moved to Jasper county, Iowa, and
in October, 1873, to Davis county and engaged in the
practice of medicine at Troy.
He had studied medicine with Dr. A. T. Marshall
of Douglas county, Illinois, before entering the army
and after locating in Troy, attended lectures at the
College of Physicians and Surgeons, Keokuk, re-
ceiving his diploma December 16, 1875.
In February, 1866, he was married to Miss Addie
L. Moore in Jasper county, who with three children
survive him.
Dr. Gilbert Baldwin of Ruthven died at his home
December 16, 1921. Dr. Baldwin was born at Pick-
wick, Minnesota, October 23, 1859. He received his
preliminary education at the commons schools of
Oelwein, Davenport, Dubuque and Burlington, Iowa,
and graduated in medicine from the medical depart-
ment of Washington University, St. Louis, Missouri.
Located in Ruthven in the spring of 1882 where he
practiced since that time, nearly forty years.
Dr. Baldwin was a member of the Palo Alto
County Medical Society, of the Iowa State Medical
Society, the American Medical Association and the
American Association of Railway Surgeons. He was
local surgeon for the C. M. & St. P. and M. & St. L.
Railways. On March 20, 1904, Dr. Baldwin was mar-
ried at Spencer, Iowa, to Miss Bessie Larson who
survives him, and also one son, Percy G. Baldwin.
Cornelius M. Morford, Toledo, Iowa; State Uni-
versity of Iowa, College of Homeopathic Medicine,
Iowa City, 1890; mayor of Toledo, from 1907 to 1915;
former president of the Hahnemann Medical Asso-
ciation died September 6, 1921, aged fifty-six — Jour-
nal of A. M. A.
Dr. H. D. Chamberlain, seventy-three years of age,
formerly of Nevada, died at Colorado Springs, De-
cember 31, 1921.
Dr. Chamberlain was born in Grand Isle county,
Vermont. Graduated from Oberlin College, and in
medicine from the University of Vermont. Soon
after receiving his medical degree located in Toledo,
122
Journal of Iowa State Medical Society
[]\Iarch, 1922
Ohio, and in 1885 located in Nevada, Iowa, where he
practiced about thirty-five j^ears.
After the death of Airs. Chamberlain, his home
was broken up, and he divided his time with his soii
in California, and with his daughter in Colorado
Springs. During the epidemic of influenza, and
pneumonia when there was a shortage of doctors on
account of the war Dr. Chamberlain offered his ser-
vices to the state to go wherever needed.
For the past two years. Dr. Chamberlain lived
with his daughter. Airs. Beulah Chamberlain Brown
of Colorado Springs. His son. Dr. Harry D. Cham-
berlain, is practicing medicine in Los Angeles, and
his youngest daughter, Aliss Alice Chamberlain, is in
missionarj' work in India, at one time in Ceylon con-
nected with a mission school. Dr. Chamberlain was
for many years a member of Story County Aledical
Society and of the Iowa State Aledical Society.
Dr. F. H. Little, Aluscatin’s most prominent physi-
cian died at his home in Aluscatine from apoplexy,
January 12, 1922. Dr. Little was born in Aluscatine,
1857. Graduated from the Aledical Department of
the Iowa State University in 1879, and at once en-
tered upon the practice in his native city where he
had practiced fortj-three years, until suddenly called
to his last account. During all these years, he had
enjoyed the respect and confidence of a large circle
of friends and neighbors. He was active and inter-
ested in all public matters and also in professional
affairs.
He was surgeon general on Governor Boies’ staff
for four years; was a member of the National Asso-
ciation of Alilitary Surgeons, also a member of his
county and State Aledical Societies and of the Amer-
ican Aledical Association. He was a Fellow of the
American College of Surgeons and of numerous civic
societies.
Dr. John White of Dubuque died at Finley Hos-
pital, December 17, 1921.
Dr. White was born in Picton, Ontario, February
11, 1854, the son of Alfred and Lydia White. He
was educated at the Chicago College of Pharmacy
from which he graduated in 1888, and a diploma from
the American College of Dental Surgery in 1891.
In 1892 graduated from the Bennett Aledical College
and in 1907 from the Indiana College of Aledicine.
He had practiced in Dubuque for the past seven
years.
MARRIAGES
Dr. Warren E. AIcCray of Lake City and Aliss
Alary Ashton of Des Aloines, November 28, 1921.
A NEW LOCAL ANESTHETIC
From time to time new anesthetics to take the
place of cocaine have been proposed, and to some
extent used, but without utterly supplanting the
older and rather dangerous drug. Now, however,
the surgeon has a substitute that is a decided im-
provement. The new local anesthetic is called
Butyn (pronounced Bute-in, with the accent on the
first syllable). It is the discovery of Professors
Roger Adams and Oliver Kamm of the University
of Illinois and Dr. E. H. Volwiler of The Abbott
Laboratories, Chicago.
The anesthetic has been passed by the Council on
Pharmac}' and Chemistrjq of the American Medical
Association. In his report. Dr. A. E. Bulson, Jr.,
for the committee on local anesthesia, section of
ophthalmology, said that it acts more rapidly than
cocaine and its action is more prolonged. Less is
required, and in the quantity necessary it is less
toxic than cocaine. It has other advantages which
make it highly useful, especially for eye work. A
solution can be boiled without impairing its effi-
ciency.
The Abbott Laboratories is supplying Butyn, in
tablets (with and without epinephrin) and 2 per
cent solutions, which may be had without narcotic
blanks.
DRUGGISTS AND PHYSICIANS
President George Jurisch has been in conference
with some of the leading officers of the Iowa Aledi-
cal Societ}' to effect an arrangement for establishing
better harmony between the two organizations. His
suggestion was very cordially received and the pres-
ident of the Iowa Aledical Society will appoint a
committee of three to meet a like committee of the
Iowa Pharmaceutical Association. These two com-
mittees are to endeavor to suggest measures by
means of which the physicians and pharmacists may
work in closer harmony. Such a combined commit-
tee could iron out a good many of the differences
that now exist between the two organizations. —
Northwestern Druggist.
BOOK REVIEWS
HISTORY OF AIEDICINE
With Aledical Chronology, Suggestions for
Study and Biographic Data by Fielding H.
Garrison, AI.D., Lt. -Colonel, Aledical Corps,
U. S. Army, Surgeon General’s Office, Wash-
ington, D. C. Third Edition Revised and
Enlarged, Octavo of 942 Pages with 257 Por-
traits. W. B. Saunders Company, 1921.
Price $9.00 Net.
The study of the history of medicine offers many
attractions to the physician of culture, and the phy-
sician who cannot turn to the important facts of his
own profession may not expect the confidence and
respect of the better educated portion of the com-
munity for his learning. The advancement of medi-
cal science is a sensitive gauge of the progress of
civilization. The period from Hippocrates to Galen,
VoL. XII, No. 31
Journal of Iowa State Medical Society
123
to Sydenliam, to John Hunter, to Pasteur and Lister,
a period of about 2300 years marks the slow and
painful progress of civilization. It seems a long time
for medicine to reach the scientific period, well
within the recollection of men practicing today. But
the scientists had not discovered the means to de-
termine the minute organisms that produce most of
the diseases from which mankind suffers, many
things transpired that brought medicine almost to
the point of full development. Harvey discovered
the circulation of the blood, but other men came
very near reaching the same point. Pasteur dis-
covered the relation of microorganisms to disease,
but others had speculated on the nature of infections.
Walter Reed discovered the real cause of yellow
fever but others had connected the mosquito with
malaria and yellow fever.
Koch discovered the cause of tuberculosis but
Villeman had noticed the infectious nature of pul-
monary tuberculosis. Louis and Laennec had
worked out methods of accurate examination of the
lungs. Auenbrugger auscultation and percussion.
Morton and Long are credited with the administra-
tion, of ether for anesthesia in surgical operations.
But others had made this possible. And so we may
include all the great discoveries in medicine. Even
Jenner received his inspiration from milk maids.
With great industry and perseverance, Colonel
Garrison with the surgeon general’s library at his
command has worked out as far as possible the
contributions of each man and groups of men in this
long period of time. The work is arranged in chron-
ological order, beginning with the earliest records of
the means of healing the sick to a knowledge of dis-
ease including the progress of the science of medi-
cine from the use of the microscope in the study of
tissue changes, the study of microorganisms and
their relations to disease up to the present day.
In addition to the historical data there is pre-
sented a short biographical sketch of the men to
whom medicine is indebted, the nature and value of
their contributions, accompanied by excellent pic-
tures which helps us to form an idea of the intellectual
qualities of the men who brought medicine to its
present state.
EPHRAIM McDowell— “FATHER OF OVAR-
IOTOMY” AND FOUNDER OF AB-
DOMINAL SURGERY
With an Appendix on Jane Todd Crawford
by August Schachner, M.D., F.A.C.S., Louis-
ville, Kentucky. Octavo Volume of About
350 Pages. Attractively Printed and Pro-
fusely illustrated with Plates in Double Tone.
Price $5.00. J. B. Lippincott Company, Pub-
lishers. Philadelphia and London.
The story of Ephraim McDowell’s life is a story
X)f the greatest interest and also of the greatest neg-
lect to which one of the foremost heroes of medicine
and benefactors of humanity has ever been exposed.
The motive of the book is to call attention to this
neglect and to arouse an interest in this pioneer mas-
ter of abdominal surgery.
The lessons which McDowell’s ovarian surgery
taught are thoroughly emphasized. The author ex-
plains how abdominal surgery gradually evolved
from the facts which these lessons so clearly and
firmly establish and why McDowell is credited with
the title of founder of abdominal surgery.
The struggle which attended the adoption of
ovariotomy and which lasted for fully a half a cen-
tury is vividly set forth, and the persecutions to
which the earlier defenders were subjected is of the
keenest interest. It was not until 1861, ^r more
than a half century after McDowell’s first ovari-
otomy before a favorable word was said for it by a
French professor in a French university. In Eng-
land the situation was very little better as it was not
until a third of a century thereafter that a London
hospital could boast of a successful ovariotomy.
A fascinating review of the more important events
of that interesting period and place in which he
practiced is interwoven throughout the narrative.
It is a review of the times and contains sketches of
persons who directly or indirectly became associated
with the man and his work during his own period
and the period that followed.
The importance of the frontier in medicine and in
the development of our national characteristics are
strikingly portrayed.
The book contains the first real attempt to present
a history of the heroine whose co-operation made the
premier ovariotomy a possibility. This feature in-
volved a patient and an unusual investigation that
ended in the discovery of her grave in an obscure
cemetery almost a century after her death.
It contains an elaborate bibliography and a care-
fully prepared index that makes it valuable as a work
of reference upon McDowell and his time but also
upon ovariotomy and the earliest efforts in ab-
dominal surgery. It should find a place in every
reference library technical or otherwise, and no sur-
gical library is complete without this long delayed
effort upon so important and such a fundamental
subject.
We are under a debt of gratitude to Dr. Schachner
for an exhaustive and analytic biography of Dt.
Ephraim McDowell, who like many other pioneer
observers and discoverers has been misrepresented
and misunderstood for many years by persons seek-
ing to gain credit thereby. But finally, the truth pre-
vails and the credit is duly accorded. The author of
this biography by a most thorough anlaysis has
clearly shown what kind of a man McDowell was
and how much is due him in laying the foundation
of abdominal surgery.
The world has accepted Dr. Ephraim McDowell
as the first real ovaritomist but did not know much
of him except he was a frontier Kentucky countrj'
doctor.
124
Journal of Iowa State Medical Society
[March, 1922
GENERAL PATHOLOGY
By Horst Oertel, Strathcona Professor of
Pathology and Director of the Pathological
Museum, and Laboratories of McGill Uni-
versity, and of the Royal Victoria Hospital,
Montreal, Canada. Published by Paul B.
Hoeber, New York.
The outstanding idea in this work appears to be
the emphasis placed upon the mechanical explanation
of the phenomena of health and disease. This is
evidenced in the author’s foreword, in which he
warns that the true understanding of pathological
processes cannot be attained through the “metaphy-
sical conceptions of use, harm, defense, vital forces,
conscious purpose, etc., but entireK' as expressions of
physico-chemical laws.”
The book is not illustrated and only a few charts
appear in the text, as the author considers that on
account of the manner in which the subject is han-
dled, being a discussion of pathological processes,
illustrations would not at all enhance the usefulness
of the work.
The various forms of bacteria are considered, not
at as great length as would be necessary in a book
dealing primarily with these organisms, yet giving
enough space to each, to show their relations to the
pathology produced and to each other.
The chapter on Immunity is very full, discussing
the various phases of the subject, and the theories as
to how immunity is explainable. A very clear expo-
sition is contained in this chapter, on hemolysis and
the nature of the Wassermann reaction. Of par-
ticular interest in this connection, are the views of
the author in regard to the exact nature of chemo-
taxis and phagocytosis, showing that these are, in his
opinion as well as of other writers, phenomena
fundamentally dependent upon surface tension
changes.
Four short chapters follow on Physical and Chem-
ical Factors as the Cause of Disease, before taking
up the consideration of subjects closely related to
each other. Disposition and Idiosyncrasy, and Hered-
ity. Oertel holds that Idiosyncrasy is a phase of ana-
phylaxis and that the solution of the problems of
disposition, rests upon a knowledge of the principles
of heredity. His ideas on the latter topic maj' be
here quoted to advantage. “We may therefore con-
clude that as far as hereditar}' qualities are con-
cerned, evidence points to a fixed endowment of an
individual by his ancestral tree. No conclusive evi-
dence has so far been furnished that environmental
influences do, in metazoa, anything but shape and
develop latent qualities and that natural selection
goes beyond strengthening them.”
-■Ml pathological changes are, by Oertel, grouped
in two great classes, first, those occurring in local
cell relations, and, second, those relating to general
cell, tissue, and organ interrelations. Lender local
cell changes, two sub-classes are shown. Inflamma-
tion and Tumors. Under general interrelations are
classed. Disturbances in Blood and Lymph Circula-
tion, Disturbances of Internal Secretion, and of
Specific Metabolism and Fevers.
The author throughout the book discusses dis-
ease causation in broad terms. According to him,
developmental processes, postnatal and retrogressive
evolutionary changes are physiological when in or-
derly and proper relation with each other, and that
the same processes become pathological when such
interrelation is disturbed.
It is to be hoped that the author’s contemplated
volume on the diseases of special organs and sys-
tems, will be written soon. — Major H. R. Reynolds,
Public Health Service.
EPIDEMIOLOGY AND PUBLIC HEALTH
In Three Volumes. By Victor C. Vaughan,
M.D., L.L.D., Volume I. Respiratory In-
fections. Published by C. V. Mosby Com-
pany, St. Louis, Mo.
The reader of Dr. Vaughan’s book is impressed by
several things which stamp it as the crowning effort
of the author’s pen and a monumental work on a
subject in which the profession and the laity alike
are showing a growing interest. We may first men-
tion the size of the work, of which only the first of
three volumes has been issued. Many medical works
are voluminous but deadly dull, while here the re-
verse is true. In this instance the size of the book
is due to the amount of inquiry into the history of
the various diseases from the earliest recorded spec-
ulations as to how and why, down to the modern
methods of research. Dr. Vaughan mentions the
fact that every known source of information was
consulted, which is amply shown by the references
to, and quotations from the various medical writers
The style in which the book is written is another
outstanding feature, contrasting with the uninterest-
ing monotonj" before mentioned. In each disease
discussed, the history is fully considered as being of
interest not only in an academic sense but showing,
as in the chapter on Cerebrospinal Meningitis, how
and when it was graduallj- differentiated from the
class of diseases which had formerly been grouped
under the term of Typhus.
The author considers all the theories and argu-
ments of many students of epidemiology, but does
not hesitate. to state very plainly his own views, with
his reasons for the variance, if there be such. An-
other salient feature is the amount of material placed
at the disposal of Dr. Vaughan and his associates.
Dr. Henry F. Vaughan and Dr. George T. Palmer,
through their connection with the Army Medical
Corps during the World War, as well as Dr.
Vaughan’s service in the Spanish .-American AVar,
and the experience of Drs. Henry Vaughan and
Palmer in the City of Detroit.
Chapter I considers the three theories as to the
causation of the classes of diseases here treated,
(Continued on Adv. Page xvi)
Journal of Iowa State Medical Society
XV
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In obstetrical and surgical work Pituitary
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Either may be used in emergency.
Elixir of Enzymes is a potent and palatable
preparation of the ferments active in acid
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of minor alimentary disorders and a fine
vehicle for iodides, bromides, salicylates,
etc.
As headquarters for the organotherapeutic
agents, we offer a full line of Endocrine
Products in powder and tablets (no com-
binations or shotgun cure-alls).
Armour’s Sterile Catgut Ligatures are made from raw ma-
terial selected in our abattoirs, plain and chromic, regular and
emergency lengths, iodized, regular lengths, sizes 000-— 4.
Literature on Request
ARMOUR^COMPANY
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for approved therapeutic purposes in the
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Careful consideration will be given inquiries concerning cases
in which the use of Radium is indicated
BOARD OF DIRECTORS
William L. Baum, M.D.
N. Sproat Heaney, M.D.
Frederick Menge, M.D.
Thomas J. Watkins, M.D.
THE PHYSICIANS RADIUM ASSOCIATION
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Telephones:
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William L. Brown, M.D.
When writing to advertisers please mention The Journal of Iowa State Medical Society
XVI
Journal of Iowa State Medical Society
BOOK REVIEWS
(Continued from Page 124)
The Theory of Supernatural Origin, The Miasmatic
Theory, and The Theory of Contagion. Chapters
II to IX inclusive, discuss these various diseases,
while the final chapter is on Weather and Disease.
In a year marked by a revival of medical publish-
ing, this book stands as one of the foremost produc-
tions. The issuance of the other volumes of the
work will be awaited with interest and pleasurable
anticipation. — Major H. R. Reynolds, U. S. Public
Health Service.
WESTERN ELECTRO-THERAPEUTIC
ASSOCIATION
The fourth annual meeting of this organization
will be held, as usual, in the Little Theatre, Kansas
City, April 20-21. Dr. Curran Pope, of Louisville, is
the president this j'ear, and will give the annual
presidential address on Thursday evening.
The program is now being made up, and will be
fully up to the standard of the previous meetings
held by this organization, whose watchword is prog-
ress. A number of men of national reputation will
be present; among those who have responded to the
invitation to read papers may be mentioned: Drs.
James T. Case, Battle Creek; A. J. Pacini, Washing-
ton; T. Howard Plank, Chicago; William L. Clark,
Philadelphia; Harry Bowing, Mayo Clinic; A. D.
Willmoth, Louisville; J. D. Gibson, Denver, and
others. Dr. . Virgil C. Kinney of New York, presi-
dent of the American Electro-Therapeutic Associa-
tion, and Surgeon-General Gumming of the U. S.
Public Health Service, have givea us a partial
promise to be with us, and all indications point to-
ward a large attendance.
The banquet will be held on Thursday evening, and
a number of distinguished speakers will be on the
program.
The exhibit hall will, as usual, contain the last
word in equipment, and the exhibit alone will be
worth a trip to Kansas City.
Dr. Grover’s School of Electro-Therapy will hold
its sessions, preceding our meeting on the 17, 18 and
19 of April, announcement of which will be found on
another page of this issue.
CHARLES WOOD FASSETT, Sec’y.
ANNUAL MEDICAL CLINIC
The Iowa State Medical College will hold its an-
nual medical clinic this year on April 11 and 12. The
usual program of clinics for the two days will be
given and Dr. A. 1. Carlson, professor of physiology
at University of Chicago will give the address on the
subject of endocrinology. This should be of special
interest to the profession at this time and Dr. Carlson
will be able to give the very latest in the line.
IOWA STATE MEDICAL SOCIETY OFFICERS
AND COMMITTEES 1921-1922
President Alanson M. Pond, Dubuque
President-Elect Charles J. Saunders, Fort Dodge
First Vice-President S. A. Spilman, Ottumwa
Second Vice-President _....M. A. Tinley, Council Bluffs
Secretary Tom B. Throckmorton, Des Moines
Treasurer .Thos. F. Duhigg, Des Moines
Editor _...D. S. Fairchild, Sr., Clinton
COUNCILORS Term Expires
First District — R. S. Reimers, Ft. Madison 1925
Second District — Henry Albert, Iowa City — 1922
Third District — A. G. Shellito, Independence, Secretary 1926
Fourth District — Paul E. Gardner, Chairman 1924
Fifth District — George E. Crawford, Cedar Rapids 1923
Sixth District — O. F. Parish, Grinnell 1923
Seventh District — Channing G. Smith, Granger 1924
Eighth District — Samuel Bailey, Mount Ayr 1924
Ninth District — A. L. Brooks, Audubon 1922
Tenth District — \V. W. Beam, Rolfe 1926
Eleventh District — G. C. Mooreland, Ida Grove 1925
TRUSTEES
J. W. Cokenower, Des Moines 1922
W. B. Small, Waterloo 1924
T. E. Powers, Clarinda 1923
DELEGATES TO A. M. A.
L. W. Dean, Iowa City 1922
W. L. Allen, Davenport 1922
J. C. Rockafellow, Des Moines 1923
ALTERNATE DELEGATES
M. J. Kenefick, Algona — 1922
J. H. Peck, Des Moines — 1922
M. N. Voldeng, Woodward — 1923
COMMITTEES
Medico-Legal
D. S. Fairchild, Sr., Clinton — 1924
Lewis Schooler, Des Moines — — 1923
H. B. Jennings, Council Bluffs 1922
Scientific Work
Alanson M. Pond Dubuque
Tom B. Throckmorton Des Moines
Thos. F. Duhigg Des Moines
Public Policy and Legislation
W. W. Pearson - Des Moines
B. L. Eiker - - Leon
D. J. Glomset - - - - Des Moines
Alanson M. Pond Dubuque
Tom B. Throckmorton Des Moines
Health and Public Instruction
Henry Albert, Iowa City 1922
Jeannette F. Throckmorton, Chariton 1923
F. H. Conner, Nevada 1924
Constitution and By-Laws
V. L. Treynor...„ Council Bluffs
C. B. Taylor,...- Ottumwa
J. T. McClintock Iowa City
Publication
D. S. Fairchild, Sr., Clinton
W. L. Bierring Des Moines
C. P. Howard Iowa City
Finance
C. P. Frantz — — Burlington
A. E. King...- Blockton
E. C. McClure Bussey
Arrangements
Alanson M. Pond - Dubuque
Tom B. Throckmorton — Des Moines
Thos. F. Duhigg — Des Moines
Two members from Polk County Medical Society.
Alan SON ]\I. Pond, M.D.
PRESIDENT
Iowa State Medical Society
1921-1922
Jfouraal of tfie
3|ob)a ^tate jfHetiual
VOL. XII
Des Moines, Iowa, April 15, 1922
No. 4
IOWA STATE MEDICAL SOCIETY
SEVENTY-FIRST ANNUAL SESSION
DES MOINES
MAY 10, 11, 12, 1922
program
OPENING EXERCISES
Wednesday, May 10
8:30 a. m.
Call to Order by the President —
Alanson M. Pond, M.D., Dubuque
Invocation — Rt. Rev. Thomas Drumm, Des Moines
Address of Welcome for the City —
Hon. Carlton M. Carver, Mayor City of Des Moines
Address of Welcome for the Profession —
-Alva P. Stoner, M.D., Des Moines,
President. Polk County Medical Society
Response — Frank M. Fuller, M.D., Keokuk
SCIENTIFIC PROGRAM
Section on Medicine —
Chairman, Evan S. Evans, M.D., Grinnell
Section on Surgery —
Chairman, George Kessel, M.D., Cresco
Section on Ophthalmology, Otology and Rhino-
laryngology —
Chairman, Fred F. Agnew, M.D., Independence
Official Reporter —
Miss Adelaide Folsom, Ripon, Wisconsin
Wednesday, May 10
9:00 a. m.
1. Pyloric Stenosis of Infancy —
Harold L. Brereton, M.D., Emmetsburg, tuenty mim4tes
Discussion opened by Matthew L. Turner, M.D., Des
Moines, five minutes
2. Market Milk from a Medical Standpoint —
Frederick G. Murr.\y, M.D., Cedar Rapids, twenty minutes
Discussion opened by Daniel C. Steelsmith, M.D., Du-
buque, five minutes
3. Surgery of the Thyroid Gland —
Paul A. White, M.D., Davenport, twenty minutes
Discussion opened by John E. O’Keefe, M.D., Waterloo,
five minutes
4. Address of Chairman Section on Medicine:
Medical Ideals —
Evan S. Evans, M.D., Grinnell, thirty minutes
5. Injuries to the Spine not Involving the Cord —
Oliver J. Fay, M.D., Des Moines, twenty minutes
6. Vertebral Fractures with Cord Involvement —
John W. M.artin, M.D., Des Moines, twenty minutes
Discussion (papers Nos. 5 and 6) opened by Willia.m
Jepson, M.D., Sioux City, H. C. Eschbach, M.D.,
Albia, and C. E. Ruth, M.D., Des Moines, fifteen
minutes
Wednesday, May 10
1:30 p. m.
7. Oration in Medicine —
Bert L. Eiker. M.D., Leon, thirty minutes
8. Subacute Bacterial Endocarditis —
Walter L. Bierring, M.D., Des Moines, twenty minutes
Discussion opened by Campbell P. Howard, M.D., Iowa
City, five minutes
9. Address on Medicine — Digitalis Results in Cer-
tain Types of Cardiac Disease (Lantern
Demonstration) —
Henry A. Christian, M.D., Professor of Medicine Harvard
Unii^rsity, Boston
10. Muscle Rigidity: Its Diagnostic Value —
Clyde A. BoicE, M.D., Washington, twenty minutes
Discussion opened by Peter A. Bendixen, M.D., Davenport,
five minutes
11. Fracture of the Patella —
Jasper L. Augustine, M.D., Ladora, twenty minutes
Discussion opened by Whitfield W. Hansell, M.D.,
Grinnell, five minutes
Adjournment
3:30 p. m.
Meeting House of Delegates
126
Wednesday Evening, May 10
Social Entertainment
Thursday, May 11
9:00 a. m.
12. A Survey of Two Hundred Cases of Pulmonary
Tuberculosis —
John \V. Shuman, M.D., Sioux City, tzventy minutes
Discussion opened by Herbert V. Scarborough, M.D.,
Oakdale, fize minutes
13. Surgical Diagnosis of Gall-Bladder Disease —
Lake H. Fritz, M.D., Dubuque, twenty minutes
Discussion opened by Walter L,. Bierring, M.D., Des
Moines, five minutes
14. Some Variations in the Thoracic Content as
Observed in the Anatomical Laboratories of the
State University —
Henry J. Prentiss, M.D., Iowa City, twenty minutes
Discussion opened by Ch.\rlES H. Magee, M.D., Burlington,
five minutes
15. General Septic Peritonitis and Its Treatment —
Aram G. Hejinian, M.D., Anamosa, twenty minutes
Discussion opened by Michael J. KenEFIck. M.D., Algona.
five minutes
16. Tumors of the Breast —
William Jepson, M.D., Sioux City, twenty minutes
Discussion opened by Wm. L. Allen, M.D., Davenport,
five minutes
17. Diagnostic Problems in the Right Upper Quad-
rant—
Judd C. Shellito, M.D., Independence, twenty minutes
Discussion opened by Charles S. James, M.D., Centerville,
five minutes
Thursday, May 11
1:30 p. m.
18. Chemistry and Medicine —
Pearl E. Somers, M.D., Grinnell, tzeenty minutes
Discussion opened by Robert L. Parker, M.D., Des Moines,
five minutes
19. Address of the Chairman of Section on Surgery —
The Control of the Circulation —
George Kessel, M.D., Cresco, thirty minutes
20. Address on Surgery — Our Present 4vnowledge
and Experience Concerning Caesarean Section
(Lantern Demonstration) —
Edward P. Davis, M.D., Professor of Obstetrics Jefferson
Medical College, Philadelphia
21. Extraperitoneal Caesarean Section —
Nicholas Schilling, M.D., New Hampton, twenty minutes
Discussion opened by Arthur H. McCrEight, M.D., Fort
Dodge, five minutes
22. Multiple Sclerosis —
Lena a. Beach, M.D., Rockwell City, twenty minutes
Discussion opened by Clarence E. Van Epps, M.D., Iowa
City, five minutes
[April, 1922
23. Spinal Puncture as an Aid to Diagnosis and
Therapeusis —
John F. Herrick, M.D., Ottumwa, twenty minutes
Discussion opened by Joseph W. Rowntree, M.D., Water-
loo, five minutes
24. Differential Diagnosis between Infection of
Bone and Sarcoma of Bone (Lantern Demon-
stration)—
Howard L. Beye, M.D., Iowa City, twenty minutes
Discussion opened by Donald Macrae, Jr., M.D., Council
Bluffs, five minutes
Thursday Evening
8:00 p. m.
25. President’s Address —
Alanson M. Pond, M.D., Dubuque
26. Address Guest of Section on Ophthalmology,
Otology and Rhinolaryngology — The Pros and
Cons of Foreign Protein Injections in Affec-
tions of the Eye —
James McDowell Patton, M.D., Omaha
Buffet Luncheon and Smoker following Scientific Program
Friday, May 12
9:00 a. m.
27. Plastic Medicine —
James G. Macrae, M.D., Creston, twenty minutes
Discussion opened by Frank E. Sampson, M.D., Creston,
fir'e minutes
28. Pelvic Infections —
John E. Brinkman, M.D., Waterloo, twenty minutes
Discussion opened by Edward L. Rohlf, M.D., Waterloo,
five minutes
29. Anterior Poliomyelitis: A Review of Thirty
Sporadic Cases —
Cyril G. Field, M.D., Fort Dodge, twenty minutes
Discussion opened by Frank A. Ely, M.D., Des Moines,
five minutes
30. The Postoperative Treatment of Peritonitis —
Harry E. PfEiefer, M.D., Cedar Rapids, twenty minutes
Discussion opened by Ralph E. KeysEr, M.D., Marshall-
town, five minutes
32. Oration on Surgery —
Charles E. Ruth, M.D., Des Moines, thirty minutes
Report of Transactions House of Delegates —
Tom B. Throckmorton, M.D., Secretary, Des Moines
OPHTHALMOLOGY. OTOLOGY AND RHINO-
LARYNGOLOGY
Chairman
Fred F. Agnew, M.D., Independence
Thursday, May 11
9:00 a. m.
Address of Chairman — Occlusion of the Central
Retinal Artery — Fred F. Agnew, M.D., Independence
Journal of Iowa State Medical Society
127
Journal of Iowa State Medical Society
VoL. XII, No. 4]
1. Recurrent Hemorrhage into the Vitreous —
Martin J. Joynt, M.D., LeMars
Discussion opened by Stephen A. O’Brien, M.D., Mason
City
2. An Experience with Some Cases of Foreign
Body in the Eyeball —
William B. Small, M.D., Waterloo
Discussion opened by William F. Boiler, M.D., Iowa City
3. Diminishing Accommodation, Artificially Pro-
duced — Royal F. French, M.D., Marshalltown
Discussion opened by Elmer P. Weih, M.D., Clinton
4. The Routine Wassermann in Ophthalmology —
Harvey B. Gratiot, M.D., Dubuque
Discussion opened by James E- Reeder, M.D., Sioux City
5. Postoperative Comfort in Tonsil Cases —
John E. Rock, M.D., Davenport
Discussion opened by Lloyd G. Howard, M.D., Council
Bluffs
6. Methods for Promoting Rapid Healing in the
Mastoid Operation —
Louis L. Henninger, M.D., Council Bluffs
Discussion opened by Charles M. Werts, M.D., Des Moines
7. Obstruction of the Nasal Passages, with Special
Reference to the Upper Regions —
Harry M. Ivins, M.D., Cedar Rapids
Discussion opened by William H. Johnston, M.D., Mus-
catine
8. Stridor and Dyspnoea in Childhood —
« Jesse B. Naftzcer, M.D., Sioux City
Discussion opened by Howard E- Thompson, M.D., Du-
buque
9. The Use of the Bronchoscope and Esophage-
SCOpe — William W. Pearson, M.D., Des Moines
Discussion opened by Lee Wallace Dean, M.D., Iowa City
HOUSE OF DELEGATES
Wednesday, May 10
3:30 p. m.
Roll Call
Report of Secretary-
Report of Treasurer
Report of Council
Report of Trustees
Report of Standing Committees
Memorials and Communications
New Business
Election of Committee on Nominations
Thursday, May 11
8:00 a. m.
Roll Call
Reading of Minutes
Report of Committees
Unfinished Business
New Business
Friday, May 12
8:00 a. m.
Roll Call
Reading of Minutes
Report of Committee on Nominations
Election
Report of Committees
Unfinished Business
New Business
MEETING PLACES
Headquarters — Hotel Fort Des Moines, Tenth and
Walnut Streets
General Meetings — Hotel Fort Des Moines, Ball
Room
House of Delegates — Hotel Fort Des Moines, Third
Floor
Eye and Ear Section — Hotel Fort Des Moines, Third
Floor
Registration and Exhibits — Hotel Fort Des Moines,
Mezzanine Floor-
Headquarters for Ladies — Hotel Fort Des Moines
Rules for Papers
No paper before the Society shall occupy more
than twenty minutes in its delivery; and no member
shall speak longer than five minutes nor more than
once on the same subject. This does not applj- to
the addresses and orations.
All papers read before the Society shall be its
property. Each paper shall be deposited with the
Secretary when read, and if this is not done, it shall
not be published.
On arising to discuss a paper, the speaker will
please announce his name and address plainly.
Please remember to REGISTER.
ENTERTAINMENT
Wednesday, May 10
Reception Savery III, Three to Five O’Clock, Courtesy of the
Chamber of Commerce
Banquet, Hotel Fort Des Moines, Six-thirty; physicians, their
wives and guests
Thursday, May 11
Studio Tea from Three to Five O’Clock for Visiting Ladies at
the New Townsend Studio. Des Moines Ladies Hostesses
Theater Party for the Visiting Ladies, Courtesy of the Chamber
of Commerce, 8:00 P. M.
Buffet Luncheon and Smoker following Scientific Program
Secure Your Hotel Reservations at Once — For Hotels, See Advertising Pages iv, vi, and viii
128
Journal of Iowa State Medical Society
[April, 1922
OFFICERS 1921-1922
PRESIDENT
Alanson M. Pond, M.D. Dubuque
PRESIDENT-ELECT
Charles J. Saunders, M.D.. Fort Dodge
FIRST VICE-PRESIDENT
S. A. Spilman M.D., Ottumwa
SECOND VICE-PRESIDENT
M. A. TinlEy, M.D Council Bluffs
SECRETARY
Tom B. Throckmorton, M.D Des Moines
Health and Public Instruction
Henry Albert, M.D., Iowa City. .. 1922
Jeannette F. Throckmorton, M.D., Chariton 1923
F. II. Conner, M.D., Nevada 1924
Eugenics
Max E. Witte, M.D Clarinda
M. N. Voldeng, M.D Woodward
F. A. Ely, M.D Des Moines
Conservation of Vision and Hearing
H. G. Langworthy, M.D Dubuque
T. U. McManus, M.D Waterloo
F. E. Shore, !M.D * Des Moines
Constitution and By-Laws
\ . L. Treynor, M.D Council Bluffs
C. B. Taylor, M.D Ottumwa
J. T. McClintock Iowa City
TREASURER
Thos. F. Duhigg, M.D Des Moines
EDITOR
D. S. Fairchild, Sr., M.D Clinton
Publication
D. S. Fairchild, Sr., M.D Clinton
W. L. Bierring, M.D Des Moines
C. P. Howard, M.D Iowa City
Finance
COUNCILORS Term Expires
First District — R. S. Reimers, M.D., Ft. Madison 1925
Second District — Henry Albert, M.D., Iowa City 1922
Third District — A. G. Shellito, M.D., Independence, Sec’y 1926
Fourth District — Paul E* Gardner, M.D., Chairman 1924
Fifth District — George E. Crawford, M.D., Cedar Rapids 1923
Sixth District — O. F. Parish, M.D., Grinnell 1923
Seventh District — Channing G. Smith, M.D., Granger 1924
Eighth District — Samuel Bailey, M.D., Mount Ayr, 1924
Ninth District — A. L. Brooks, M.D., Audubon 1922
Tenth District — W. W. Beam, M.D., Rolfe 1926
Eleventh District — G. C. Moorehead, M.D., Ida Grove 1925
TRUSTEES
J. W. Cokenower, M.D., Des Moines
W. B. Small, M.D., Waterloo
T. E. Powers, M.D., Clarinda
DELEGATES TO A. M. A.
L, W. Dean, M.D., Iowa City 1922
W. L. Allen, M.D., Davenport 1922
J. C. Rockafellow, M.D., Des Moines 1923
ALTERNATE DELEGATES
M. J. Kenefick, M.D.,. Algona 1922
J. H. Peck, M.D., Des Moines 1922
M. N. Voldeng, M.D., Woodward 1923
C. P. Frantz, M.D Burlington
A. E. King, M.D Blockton
E. C. McClure, M.D Bussey
Field Activities Committee
Frank E. Sampson, M.D Creston
Donald Macrae, Jr., M.D Council Bluffs
Alanson M. Pond, M.D , Dubuque
Medical Library
David S. Fairchild, M.D Clinton
Walter L. Bierring, M.D Des Moines
Oliver J. Fay, M.D Des Moines
Gershom H. Hill, M.D Des Moines
George Royal, M.D *...Des Moines
Arrangements
Alanson M. Pond, M.D Dubuque
Tom B. Throckmorton, M.D Des Moines
Thos. F. Duhigg, M.D Des Moines
W. E. Sanders, M.D Des Moines
W. J. Fenton, M.D Des Moines
STATE SOCIETY
IOWA MEDICAL WOMEN
COMMITTEES
Medico-Legal
D. S. Fairchild, Sr., M.D., Clinton
Lewis Schooler, M.D., Des Moines
H. B. Jennings, M.D., Council Bluffs...
Scientific Work
Alanson M. Pond. M.D Dubuque
Tom B. Throckmorton, M.D . ..Des Moines
Thos. F. Duhigg, M.D Moines
Public Policy .\nd Legisl.^tion
\\'. \V. Pearson, M.D. Moines
B. L. Eiker. M.D Leon
D. J. Glomset, M.D Des Moines
Alanson M. Pond, M.D Dubuque
Tom B. Throckmorton, M.D Des Moines
TWENTY-FIFTH ANNUAL MEETING
DES MOINES
Tuesday, May 9
Headquarters
Chamber of Commerce Library, Savery III
Morning Session
9:00 a. m.
Call to Order by the President —
Josephine Wetmore Rust, M.D., Mason City
VoL. XII, No. 4]
Journal of Iowa State Medical Society
129
Invocation —
Carrie M. Beil, Secretary Women’s Department, Chamber
of Commerce
Appointment of Committees —
1. Social Hygiene a Public Health Factor —
Lillie Arnett, M.D., Waterloo
2. Health Examination of School Children —
Marian O’Harrow, M.D. (by invitation). Student Health
Department Iowa City
3. President’s Address —
Annual Business Meeting
12:45 p. m.
Luncheon — Savery Cafe
Guests of the Chamber of Commerce
Afternoon Session
2:00 p. m.
4. The Toxemias —
RosabellE a. Butterfield, M.D., Indianola
5. Hyperemesis Gravidarum —
Mary L. TinglEy, M.D., Council Bluffs
6. Eclampsia —
Clara B. Whitmore, M.D., Shanghai, China
7. Birth Control —
Pauline H. Hanson, M.D., Marshalltown
8. Our Part in Lowering the Death Rate —
Jennie M. Christ, M.D., Ames
Evening Session
6:30 p. m.
Twenty-fifth Annual Meeting — Anniversary Dinner
Crystal Room — Harris-Emery’s
Josephine Wetmore Rust Presiding
Our Society —
Its
Conception —
Edith G. Fosnes, M.D.
Its
Infancy —
Sarah Kime, M.D.
Its
Adolescence —
Agnes Eichelberger, M.D.
Its
Present —
Lena a. Beach, M.D.
Its
Future —
Jeannette F. Throckmorton, M.D.
Adjournment
OFFICERS
1921-1922
PRESIDENT
•Josephine Wetmore Rust, M.D Mason City
VICE-PRESIDENT
Jennie M. Coleman, M.D Des Moines
TREASURER
Eleanor M. Hutchinson, M.D Woodward
SECRETARY
Julia Ford Hill,. M.D Grinnell
COMMITTEE ON ARRANGEMENTS
Jennie M. Coleman, M.D Des Moines
Grace D. Crowl, M.D Des Moines
Important Announcement
All women physicians who can arrange to attend
this meeting, are requested to make their own hotel
reservations early; and are also urged to make early
reservations for the luncheon and dinner, with Dr.
Jennie M. Coleman, 3514 Second Street, Des Moines,
Iowa. As a courtesy to the speakers on the program,
please be prompt in attendance at the sessions.
OUR EXHIBITORS
Standard Chemical Co., Des Moines, Booths No. 1 and 2
Surgical Instruments, Supplies, Chemicals
Horlick’s Malted Milk, Racine, Booth No. 3
Horlick’s Milk Products
Kolynos Co., New Haven, Booth No. 4
Dental and Surgical Supplies
Merry Optical Co., Kansas City and Des Moines, Booth No. 5
Optical Goods, Surgical Instruments
Magnuson X-Ray, Omaha and Des Moines, Booth No. 6
X-Ray Apparatus and Intensifying Screens
Riggs Optical Co., Omaha, Booth No. 7
Optical Goods, Surgical Instruments
Victor X-Ray Corporation, 206 Security Bldg., Des Moines
X-Ray Equipment and Physio-therapy Apparatus
The Radium Company of Colorado, Chicago and Denver, Booth
No. 10
Demonstration Use of Radium
Geneva Optical Co., Des Moines, Booth No. 11
Optical Goods and Specialties
Lewis X-Ray Co., 514-18 Utica Bldg., Des Moines
The wonderful advancement in X-Ray Apparatus will be
shown in Booths No. 12 and 13
E. R. Squibb and Sons, New York, Booth No. 14
Vaccines, Serums and Antitoxins
G. H. Sherman, M.D., Detroit, Booth No. 15
Bacteriological Laboratories, Bacterial Vaccines
W. B. Saunders Co., Philadelphia, Booth No. 16
Medical Books and Publications
Radium Chemical Company of Pittsburg, Booth No. 17
Demonstration L’se of Radium, and Apparatus for Adminis-
tration
W. G. Cleveland Co., Omaha and St. Louis, BoAh No. 21
Surgical Instruments, Orthopedic Appliances, Office and
Hospital Supplies
The Medical Protective Co., Ft. Wayne, Booth No. 23
Iowa State Medical Library, Des Moines
Ground Gripper Boot Shop, 509J4 Sixth Ave., Des Moines, Booth
No. 22
Demonstrating Ground Gripper Shoes
130
Journal of Iowa State [Medical Society
[April, 192.?
THE DES MOINES SESSION
Again, another year has rolled around, and Des
[Moines, having been selected by the House of Dele-
gates last year as the meeting place, is preparing to
entertain the medical profession, both scientifically
and socially, at the Seventy-first Annual Session of
the Iowa State [Medical Society. The dates of the
meeting are May 10, 11 and 12. For four consecutive
j'ears, the House of Delegates has seen fit to ac-
cept the invitation of its local members, and Des
[Moines has been accorded the unique distinction of
entertaining the profession of the state during the
last four sessions. That the hospitality thus ex-
tended has been mutual, is well attested by the inter-
est shown in the increasing number of visiting mem-
bers each year and by the unfeigned pleasure af-
forded the local profession in having the visiting
physicians among them.
Program
As has been customary, the current issue of the
Journal contains the official program. The Scien-
tific Committee, with the generous help of the Sec-
tion Chairmen, has endeavored to gather together a
collection of papers to be presented by representa-
tive men, not only as contributions by members of
the State Societj*, but by guests of national and in-
ternational reputation as well.
It will be a great honor, and a tribute to Iowa
medicine, to have as guests of our profession, a rep-
resentative of the oldest medical college in this coun-
try, Dr. Henry A. Christian of Harvard Medical Col-
lege, Boston; a representative of the only independ-
ent medical college now existing in this country;
Dr. Edward P. Davis, Jefferson [Medical College,
Philadelphia; and a representative of one of the best
known medical colleges in the Mid-West, Dr. James
Patton, Medical Department of the University of
Nebraska, Omaha.
None of these guests need special introduction to
the members of the Iowa profession. Dr. Christian
is the Hershey Professor of [Medicine in the Harvard
Medical College, and will deliver the Address on
Medicine. Dr. Edward P. Davis, for many years, has
filled the chair of Obstetrics in the Jefferson Medical
College, succeeding the illustrious Theophilus Par-
vin, to that position many years ago. Dr. Davis will
deliver the Address on Surgery. Dr. James [M.
Patton, as an associate to Dr. Harold Gifford, needs
no special introduction as his reputation, as well as
that of his Chief, long ago drifted eastward across
the ^lissouri River and has been well established in
the Hawkeye state. Dr. Patton will deliver the Ad-
dress for the Section on Ophthalmology, Otology
and Rhinolaryngology.
Headquarters and Meeting Place
The Scientific Committee, acting as a result of ic.s
former experiences, has again selected the Hotel
Fort Des [Moines as the General Headquarters and
Meeting Place of all the scientific assemblies, the
special meeting place of the Eye, Ear, Nose and
Throat Section, the House of Delegates, and the
Scientific Exhibit. Everything for the comfort ot
the phr-sicians, their guests and friends, during the
session, has been assured by the hotel management.
Commercial and Scientific Exhibits
The Commercial and Scientific Exhibits by local,
state, and national firms will be held as usual in the
rooms adjoining the meeting place of the General
Sessions. Here, the annual coming together and the
renewal of acquaintainship between the Iowa ph3’si-
cians and the representatives of the various com-
mercial firms has proven of immense value and of
mutual benefit to all concerned. Each j-ear the
growing demand for exhibit space attests to the
practical value of such an arrangement.
Special Events
The Social events of the session will be con-
ducted largeh' along the same lines as have prevailed
in preceding years. On Wednesday afternoon from
three to five o'clock, the visiting ladies will be ten-
dered a reception at the Hotel Saver^'. In the even-
ing will be given the annual banquet to the physi-
cians, their wives and guests, at the Hotel Fort Des
[Moines, sixt-thirt\- o’clock. A theatre party will be
arranged for the ladies on Thursday' afternoon.
Hotel Reservations
And last, but not least, is the usual reminder to
obtain hotel accommodations earhq as it is predicted
that even a fuller attended meeting is in store this
year, and while it is presumed that the local hos-
telr\- will amph- provide for accommodations, it is
alwaj'S well for one to be on the safe side and se-
cure reservations early. So come to Des Moines
prepared to fulh- enjoj" ever\-thing connected with
the Sevent\'-First .Annual Session of the Iowa State
Medical Societ>-.
Tom B. Throckmorton, Sec’y.
TUBERCULOSIS CLINIC
The Iowa Trudeau Society, the medical section
of the Iowa Tuberculosis Association, will hold a
tuberculosis clinic conducted b\' Dr. George Thomas
Palmer of Springfield, Illinois, at the general meet-
ing place of the Iowa State Medical Society, Hotel.
Fort Des Moines, Fridajq 1:30 p. m., [May 12, 1922.
ARKANSAS MEDICAL SOCIETY HOME-
COMING
The Annual Session of the Arkansas State [Medical
Society' to be held at Little Rock, May 17, 18, 19,
will be in the nature of a “home-coming meeting.”
All former Arkansas physicians, now practicing in
other states, are cordiallj’ invited to be present. The
meeting just precedes the A. [M. A. at St. Louis, and
both may be enjoyed on the same trip.
Wm. R. Bathrust, Secretary-.
VoL. XII, No. 4]
Journal of Iowa State Medical Society
131
DISEASES OE THE BLOOD-VESSl-XS AS
SEEN IN THE EYE*
Edward J.\ckson, AI.D., Denver, Colorado
Mr. President, Members of the Iowa State Medi-
cal Society, Ladies and Gentlemen :
The session so far this evening has been of such
comparatively intimate character and general im-
portance that it seems too bad to turn, even for a
brief time, to special points that are of interest
apparently to a limited proportion of the profes-
sion. But there are so many lines of thought that
are needed to bind our profession together, that
too many opportunities cannot be found to bring
them to the attention of all members of the pro-
fession. The gap between what we learn of path-
olog}' through the microscope or on the cadaver,
and those practical questions of overshadowing
importance with which we are compelled to deal
every day in the living body, has always been too
great, and it seems as great now as ever it was.
In calling your attention to a specialty, as
seems to be my duty implied in the title of the
address, I do not wish to emphasize the import-
ance of the eye as a special field of practice, but
rather to impress its importance as a special op-
portunity for solving problems, the solution of
which will narrow and bridge this gap, between
fundamental scientific knowledge and practical
.symptomatolog}^ as we are compelled to deal
with it. The opportunities that are offered
through the study of the eye in this direction are
very large.
Circulatory Systems of the Eye
We have in the eye three very distinct blood-
vessel systems: Eirst, on the surface, the distri-
bution of vessels that in many ways resembles the
distribution of the vessels in the other mucous
membranes of the body. But here the vessels
are most clearly seen on account of the trans-
jiarency of the tissues in this location. They are
more accessible to study here, they can be studied
with a microscope of 100 diameters or more, and
thus things can be seen in the human body that
we have been accustomed to look for in the lab-
oratory' in the web of the frog’s foot or in the
mesentery of an animal. We can come into close
actual acquaintance with the circulation of the
blood in the vessels, passing from the arteries into
the capillaries and from these on into the veins,
and with the corneal microscope we have at the
edge of the cornea, particularly in the limbus, the
best field for observation of the newly' formed
*Read before the Seventieth Annual Session, Iowa State Medical
Society, Des Moines. Iowa, May 11. 12, 13, 1021.
COME HELP TO MAKE
vessels that follow certain corneal inflammations.
We are here able to see the rush of the blood,
very^ much resembling that in the web of the
frog’s foot — corpuscles hurrying along at a great
rate, then pausing, going slower and perhaps stop-
])ing altogether, and then rushing on again ; pas.s-
ing through one set of vessels more rapidly,
slower in another set. That is one system of cir-
culation in the eye.
The other two circulatory' systems within the
ey'e differ materially in certain respects. The
retinal circulation is a so-called terminal circula-
tion. The arteries divide without inosculations,
each artery- becoming the sole supply of a limited
territory. They pass on, dividing and subdividing
until they pass into the capillaries and from the
capillaries the blood is gathered back into the
veins, each one of which receives the tribute from
its particular territory with very- few inoscula-
tions. These peculiarities of arrangement are as-
sociated with marked peculiarities in sympto-
matology.
The third system comprises the vessels of the
uveal tract, of the iris and of the choroid. He.e
the inosculation of different branches is a very
striking feature, the vessels, from the circles of
the iris anastomosing freely down to the capil-
laries, and there is a perfect network of large
choroidal vessels that seem to open out freely
into each other in all directions, very much as
the capillaries do in general. With these pe-
culiarities are associated certain differences of
function.
.Such circulatory^ systems are not only found in
the eye. The terminal circulation of the retina is
very closely- similar to that found in the highly-
specialized portions of the brain. In a peculiar
and minute sense, the circulation of the brain is
represented by the circulation of the I'etina.
The effects of such distribution of blood are
readily- seen. .Some may be alluded to here, as
physiological. Most ])ersons on looking at a blue
sky, or at a uniform sky, through a blue glass, for
several minutes, can begin to see the circulation
of the blood in the capillaries of their own macula
lutea. Bodies that become more distinct the more
they- are watched under proper conditions ; may
be seen to move from the periphery of the field
toward the center, change their direction and then
move away- again, generally not crossing the point
of fixation. .Some of these will follow each other
along a certain channel, evidently marking out a
strictly- limited path. Others will follow along a
different channel and pass off in a different way-,
or sometimes two channels will join together.
The phenomena differ radically from what is
THE ATTENDANCE 1000
132
Journal of Iowa State Medical Society
[April, 1922
seen in the web of the frog’s foot or in the limbus
of the conjunctiva. These moving bodies, what-
ever their exact character may be, evidently rep-
resent the blood currents. They have a fairly
uniform velocity, in general they rush along, fol-
lowing each other at practically the same rate, the
phenomenon being in this different from that ob-
served in the capillary circulation elsewhere. I
take it that the significance of this is that in the
highly specialized portions of the nervous system,
represented in the retina and in the cortex of the
brain, uniformity of nutritive supply, freedom
from pulsation is of great importance to the
proper performance of function. Certainly when
the circulation becomes irregular in either retina
or brain, function suffers.
Pulsation of the Vessels
-\s we look at the circulation in the eye, the
absence of pulsation is very striking, as compared
with the superficial vessels and as compared with
the circulation of the blood elsewhere throughout
the body. In fact, in the majority of normal eyes
looked at with an ophthalmoscope, which gives
us fifteen or twenty diameters of magnification,
we see no pulsation whatever. With higher
powers the pulsation of the vessels can be de-
tected, but it is relatively slight.
When we do see pulsation in the normal eye,
as we do perhaps once in three or four individ-
uals, it is somewhat different from the pulsation
which we feel, or can witness elsewhere in the
body. It is not the progress of the pulse wave,
but it is an effect of the pulse wave — a remote
effect, a secondary effect, under special condi-
tions. We see the pulsation not in the arterioles,
but in the veins, and in the portion of the vein
that is just passing out of the eye. The pressure
within the vessel is opposed by the intraocular
pressure to which is added the arterial pulse wave,
so much of it as gets into the eye. The addition
of this pulse wave is often sufficient to overcome
the intravenous resistance. At the point of the
vein at which it passes out of the eye where the
venous pressure is lowest, it becomes temporarily
empty, and we see the venous pulse, which is
caused by the emptying of the vein when the
* arterial pulse wave comes into the eye. That is
about the only normal pulsation that is seen in the
eye. This pulsation, due to peculiar factors, has
a significance differing from that of the pulsation
observed elsewhere.
have a balance of forces between the intra-
venous pressure and the intra-ocular pressure
outside the veins with the intra-arterial pressure
and still other pressure that we may make on the
outside of the eye. By modifying these factors
we are able to study pulsation in the vessels as it
cannot be studied elsewhere.
Blood-Pressure in the Eye
About ten years ago Dr. IMelville Black of
Denver called attention to the importance of the
circulation in the optic nerve entrance as the
means of judging of the general blood-pressure.
Since that time the idea has been taken up and
worked on rather extensively in laboratory and
in clinic, and quite successfully in France, par-
ticularly by Bailliart, who has devised a little in-
strument for measuring approximately the pres-
sure to which the intra-ocular circulation is sub-
jected. With that, a very striking and interesting
.series of changes in pulsation can be produced
within the eye.
The intravascular pressure begins in the ar-
terial trunks at its highest, runs down through the
smaller branches and runs down still more rapidly
in the capillaries, and still runs down through the
veins, to the exit through them of blood from
the eye. So that it is lowest in the veins, next in
the capillaries, and highest in the arteries. Now,
if we take an eye that does not exhibit any pulsa-
tion and press on it slightly with the tip of the
finger, watching it by means of the ophthalmo-
scope, or press on it slightly with such an instru-
ment as that of Bailliart, we see:
Fir.st, with a slight external pressure added to
the intra-ocular pressure, the pulse wave will over-
come the intravenous pressure, and as the pulse
wave enters through the artery the vein becomes
empty where it passes out of the eye, as it does
normally in certain individuals. The first thing
that appears, then, is' the venous pulse, the pulse
of absence of blood in the vein produced by the
excess of blood coming into the eye, entering both
the central retinal artery and the choroidal vessels
through the ciliary arteries. Increase this pres-
sure gradually at first and the venous pulse in-
creases.
Press still more strongly and the venous pulsa-
tion becomes less. When intra-ocular pressure
has been increased so that even in the interval be-
tween the arterial pulse weaves it is higher than
the intravenous pressure, the blood is forced more
rapidly out of the veins, and pulsation in them
may disappear. We have thus a means of roughly
estimating venous blood-pressure.
Before the venous pulse has run this cycle, other
interesting phenomena are observable in the optic
nerve head. For observing them the normal
nerve head, or one verv slightly reddened by ex-
cess of capillarity, is best. The intracapillar\'
VoL. XII, No. 4]
Journal of Iowa State Medical Society
133
pressure is higher than that in the veins, and
after the venous pulse has reached its maximum
we begin to also shut off the supply of blood in
the capillaries of the nerve head, causing a pallor.
That pallor may show some variations, but it is
rather a striking phenomenon. If you know how
to look for it and carefully graduate your pres-
sure, there is a positive paling of the optic disk
under pressure, which means that the pressure
you are making, added to the intra-ocular tension,
represents the intracapillary pressure in the eye.
Continuing to increase the pressure on the eye,
even before the venous pulsation disappears, and
sometimes before the capillary change is noticed,
you begin to affect the arterial pulse wave. The
first effect is that when the arterial pressure is
lowest in the diastolic interval the blood ceases to
come through the artery into the eye. The intra-
ocular pressure increased by the pressure you are
making on the eye checks the arterial blood cur-
rent and there appears an arterial pulse. That
arterial pulse is at first due to a disappearance of
blood from the artery during the diastolic interval
between the pulse waves and the reddening of the
arterj’ again with the entrance of the pulse wave.
As you increase the ocular pressure the arteries
force less and less blood into the eye. The pulsa-
tion, at first becomes more striking, and then be-
comes less and less. Under sufficient pressure
the blood is kept out of the eye, not only during
diastole', but also during systole. This whole
cycle of changes can be studied in any approx-
imately normal eye. I cannot but believe that
if it is carefully looked for in connection with
various disease, its study will yield valuable re-
sults.
Pathologic Pulsations in the Eye
We have two forms of pathologic pulsations
with which those who have studied ophthalmology
have been familiar for many years, and which il-
lustrate two different conditions;
(1) Pulsation of the vessels in glaucoma.
There is with a rise of intraocular tension the
appearance, first, of a venous pulse; and with
further rise the appearance of an aterial pulse.
If in glaucoma the intra-ocular tension is up to
60 mm. and the minimum intra-arterial tension
falls as low as 50 m.m., there will be a very dis-
tinct pulsation of the arteries with every stroke
of the heart.
(2) In certain conditions the arterial pressure
during diastole falls so low that it is lower than
the intra-ocular pressure. Suppose you have an
intra-ocular pressure of 30 m.m. normally, and
in the diastolic interval the pressure in the ar-
teries falls to less than 30 mm., you get the same
arterial pulse as in excessive intraocular pressure.
It is a very striking picture. Any one can look
into the back of the eye and see it in some cases
of aortic regurgitation. Occasionally opportun-
ity occurs to see it in a case of syncope, where the
arterial pressure is temporarily depressed.
Normal Absence of Pulsation
It cannot be doubted that the relatively slight
pulsation of the blood-vessels in the eye is asso-
ciated with the peculiarly delicate function of the
retina, and doubtless it is so associated with the
function of the brain. This stopping down of
pulsation is produced by special mechanical fac-
tors ; and perhaps by vasomotor control also, but
the mechanical factors are more obvious. In the
case of the intra-ocular circulations, both those of
the retina and of the uveal tract, the blood enters
through comparatively small openings. But the
blood-vessels of. the retina keep close to their
blood supply, so that the rapidity of the currents
is not particularly cut down. On the other hand,
in the uveal tract the arteries enlarge so that the
pulsation there spreads out more or less as in a
lake. The somewhat rigid openings through
which the vascular supply enters the eye, and the
enlargements of the vessels within a rigidly closed
space, probably account for the diminished pul-
sation.
Somewhat the same conditions exist in the
cranium with reference to the circulation in the
brain. We have the entrance of the carotids
through a long, rigid, bony canal ; or the entrance
of the vertebral arteries through a similar canal.
The great bulk of the cerebral circulation is sup-
plied through such an exceptional mechanical ar-
rangement. The tendency is for the elastic ar-
teries outside of these rigid openings, to pulsate
more violently. But after the pulse wave has
passed through the rigid canal the pulsation is
reduced. Of course, we have cerebral pulsation,
all surgeons encounter it. We see it in the fon-
tanelles of young children, where the conditions
are not quite the same as for adult brains, but,
considering the size of the arteries concerned,
this pulsation is slight compared with that of
other parts of the body.
I think this idea is suggestive of one of the
phases of the adaptation of the circulation to pe-
culiar requirements of nutrition, which might be
followed farther ; but I must hurry along to some
changes equally interesting and perhaps of more
general medical importance.
Pathologic Changes in Vessel VAlls
The changes which are visible in the walls of
the vessels of the eye are quite striking. They
134
Journal of Iowa State Medical Society
[April, 1922
have been recognized ever since the ophthalmo-
scope has been in general use. They were first
regarded as associated generally with renal dis-
ease. We now know that they occur without any
renal disease whatever, that primarily they are
an indication of vascular disease. While the de-
velopment of vascular disease is always more or
less unequal, while it may affect certain special
tracts and not others, while we always see it
clinically affecting particular parts of vessels,
more than other vessels closely associated with
them, still the tendencies to organic vascular
change are general.
By examination of the very small vessels, which
we can study intelligently, within the eyeball, we
meet with the earliest evidences of vascular
disease. Through the ophthalmoscope, we can
observe the changes that have taken place in the
retina ; where the terminal circulation is espe-
cially affected by the change in the vessel walls,
because each area of nutrition is dependent on a
particular vessel; and we cannot have that par-
ticular vessel seriously impaired without getting
evidence of it in impaired function. Comparing
what we see with the ophthalmoscope with what
we learn from measurement of blood pressure by
the ordinary forms of sphygmomanometer, that
which we see with the ophthalmoscope is more
reliable, is more conclusive evidence of the gen-
eral state of the vascular system, than the blood-
pressure as taken by any apparatus that can be
applied elsewhere.
I will not go much into the details of these
changes, but there is a whole series of them.
First, we have phenomena which are dependent
on changes in the vessel walls with reference to
light. We know that light is a most delicate test
of structure. The changes that are produced by
polarization are characteristic and widely applied
in the arts. The earliest effect of vascular
change is perhaps in the walls of the arteries,
changing their optical effect on the light passing
through them. Before this change amounts to
opacity, a slight disturbance of the transmission
of light interferes with seeing the underneath
vessel where one vessel crosses the other. The
color of the artery changes to what Marcus Gunn
spoke of as “copper wire” arteries, which have
a broad light streak and-are often slightly con-
tracted and straight. These changes are the
earliest, the first stage in a progressive process,
in regard to which we can look years ahead and
see what the final result of neglect will be ; or
which we can modify materially by appealing to
our patient and explaining the situation to him.
There now resides in Denver an active business
man who, I am sure, is living today because some
twelve years ago he was thoroughly scared out
of his habits of work, his devotion to business,
and induced to give a part of his day to golf, to
take account of what he ate and drank and when
and how he ate and drank by a colleague, who
has himself been dead for ten years. The man
has been under observation from time to time
ever since, and his blood-vessels, whose walls
showed very distinct alterations twelve years ago,
now look better than they did then. A case of
this kind is worth mentioning, because it empha-
sizes the importance of early detection of these
changes and the practical value that their early
recognition may have to practitioner and patient.
Obstruction in the Intra-Ocular
Circulation
W e have obstruction of the ocular vessels from
spasm. The effects of vascular spasm have been
studied in other organs. As illustrating this type
of vascular spasm Raynaud’s disease is classic.
But the actual spasm can be observed only in the
eye. There it has been seen quite frequently, and
under conditions that are sufficiently fixed and
definite for us to learn quite a good deal about it,
that we could not learn in any other way. A very
striking case was reported by Dr. Harbridge in
which spasm of a retinal artery led to temporary
complete blindness, the attacks occurring through
a series of days as often as once in forty-five
minutes. Dr. Harbridge not only was able to
study the case himself, but had several other
prominent Philadelphia ophthalmologists witness
the same phenomenon. The ordinary treatment
for vascular disease had no effect. Potassium
iodid was given, without result ; but at the end of
several days somebody suggested that the patient
be freely purged with salts, which was done, and
his value as a clinical illustration vanished at that
time. He never had any more spasm in the ves-
sels, but he died two or three years later with
evidence of general vascular disease.
That is not the only kind of spa'sm found in
the vessels of the eye, various types of the condi-
tion having been reported. One case described at
a Vienna Clinic was watched for a month, the
spasm in the arterial wall was located and ob-
served to move slowly out towards the periphery,
narrowing the wall, cutting off the blood supply
and leaving only a small amount of blood in the
peripheral branches of the vessel. But gradually
the spasm passed off until the constricted area
disappeared and the vessel became nearly its nor-
mal caliber. This occurred in a patient in child-
bed, I think, shortly after the puerperal period,
and there have occurred a few other cases not so
VoL. XII, No. 4]
Journal of Iowa State Medical Society
135
striking as that, but in which similar conditions
have been studied.
N^ow, such changes occur in the brain. We oc-
casionally see these spasms in the eye, temporarily
blurring the sight in one eye. But what is very
much more common in general and in ophthalmic
practice is the so-called ophthalmic migraine, with
the temporary cutting off of one-half of the field
of vision, more or less. .Or perhaps only a por-
tion of the field of vision at the beginning of the
attack, and gradually spreading to other parts of
the field. Later in the attack this condition is
followed by headache, but not always. These are
cases which warrant us in assuming that in the
terminal vessels of the visual tract of the brain,
the same process is going on that we can some-
times see in the eye. The temporary spasm of the
vessels interferes with the circulation, until func-
tion is temporarily almost completely in abeyance.
Arteriosclerosis can be studied very early in
the retina. That which we call the retinal vessel
is not the vessel, but the blood column in this ;
the normal walls are transparent. What we see
is the blood column. The blood column is
changed by thickening of the endothelial lining
of the vessels, and that can be detected, often
at a very early stage. In my experience this
change is a matter of serious significance. Those
patients in whom it has been most distinct have
not lived many years. I remember but one pa-
tient who lived five or six years after these dis-
tinct narrowings in the vessels of the eye.
Then other conditions have been studied there
as nowhere else ; i. e., thrombosis and embolism.
In the early descriptions of what happened in the
retina and in the earlier plates that were published
of the ophthalmoscopic picture, were cases of
“apoplexy of the retina” so-called, a very general
distribution of small hemorrhages. Now it is
known that this phenomenon is not comparable
to apoplexy, but is a thrombosis of one or more
terminal vessels. We see it also in connection
with acute disease, as in influenza. The effects
of thrombosis in the retina are, of course, veiy
striking, with great impairment of vision.
The effects of thrombosis in the choroid are
very much less, in fact we scarcely know primary
thrombosis of the choroid. There the free in-
osculation of vessels totally changes the results of
thrombosis. We have thrombosis in the choroid,
when we see the vessels atrophy, become simply
bands of white connective tissue, but without any
preceding phenomena. This may be in a small
area in the back of the eye, or it may extend over
the whole of the visible fundus, following an in-
jury or other cause for thrombosis. But it does
not cause any such symptoms or hemorrhages as
we see in the retina. The hemorrhages belong
to this terminal circulation. The lesions for-
merly called hemorrhagic infarcts, found after
vascular lesions of the brain are probably caused
by a venous thrombosis.
In the eye we have learned that the processes of
thrombosis and embolism are closely connected in
this way : An embolism in the eye is very likely
to be followed by thrombosis. An arterial throm-
bosis starting in an endarteritis will cause closure
of the vessel. A'enous thrombosis may be partial,
without destroying the function of the retina, and
may be recovered from entirely. Cases are not ai
all rare in which the vision is cut down tempor-
arily by a venous thrombosis, but subsequently is
completely restored. I have a case of that kind
which I see occasionally and examined not long
ago. Eighteen or twenty years ago this patient
had thrombosis of one central retinal vein, that I
thought might render him blind very soon ;
but his vision again became good and has re-
mained so.
Embolism in the retina produces blindness in
the area involved, but in the choroid there are
practically no symptoms. There was reported
recently a case of very extensive pulmonary dis-
ease with extensive pulmonary thrombosis, where
the history^ of the case makes it quite clear that a
large embolus was carried into the choroidal cir-
culation, and there produced changes. It did not
cause any immediate destruction of sight ; and the
ultimate changes consisted of a few scattered
points of deposit seen in the choroid. The other
appearances remained normal.
Hemorrhage
There is one other symptom of vascular dis-
ease, and that is hemorrhage. We have learned
a lot about hemorrhage which I cannot go into
here. Eirst, hemorrhage may be due to over-
filling of the vessels, of which these retinal hem-
orrhages in connection with thrombosis are an
instance. The hemorrhage that we see in con-
nection with choking of the optic disk is a case
in point.
Then hemorrhage may arise in connection with
acute disease. We see it particularly in con-
junctivitis, in which it is simply an exaggeration
of extravasation. The extravasation that we look
for in all inflammations simply leaves out the
blood corpuscles. When the blood corpuscles are
included we have little hemorrhages, which mark
certain forms of conjunctivitis very strikingly.
We are learning in the eye those diseases that
produce the vascular changes which are at the
Secure Your Hotel Reservations at Once — For Hotels, See Advertising Pages iv, vi, and viii
136
Journal of Iowa State Medical Society
[April, 1922
bottom of hemorrhage, and in general, of the two
factors, change in blood composition and change
in the blood-vessel walls, the light thrown upon
the subject of hemorrhage in the eye indicates
that the latter are immediately connected with the
hemorrhage. \\ e can conceive that these blood-
vessel changes are dependent on changes in the
composition of the blood ; but these changes in
composition ha\ e not been letting the blood out
into the tissues, until they have caused disease of
certain points of the vessel walls, through which
the blood passes out. With the ophthalmoscope,
the source of hemorrhage may be identified, and
other parts of the same vessel seen to remain
absolutely free from hemorrhage.
In this way the connection of hemorrhage with
certain general diseases has been fairly worked
out. With syphilis there is comparatively little
hemorrhage. In certain conditions studied in the
eye we see extensive changes in the vessel wall,
but hemorrhage is not a common symptom. Hem-
orrhage is practically a universal symptom of
vascular tuberculous disease. In acute infections
hemorrhage is to be expected with vascular
changes, and particularly in influenza. And per-
haps of almost equal importance, although this
cannot as yet be accurately estimated, are the
various focal infections in causing intra-ocular
and presumably other hemorrhages.
Much more might be said of the changes that
we can observe in the living eye during the ab-
sorption of hemorrhage, or the organization pro-
ceeding in it. But I have already presumed too
long upon your patience.
RETINAL CHANGES IN CARDIO-VAS-
CULAR AND RENAL DISEASES*
James E. Reeder, IM.D., Sioux City
When requested by our chairman to present a
paper before this section, I hesitated at some
length before determining the subject I have
chosen. What prompted me to select one of this
nature, that is a subject which so much has been
written upon, was due to the fact of some recent
experiences with the internists which led me to
the conclusion there should be more cooperative
work between the ophthalmologist and the in-
ternist, as only recently I was asked to report the
fundus finding in a patient suffering from dia-
betes, the fundi showing a retinitis superimposed
upon a low grade sclerosis although the blood-
‘Presented before the Seventieth Annual Session, Iowa State
Medical Society, Des Moines, Iowa, May 11, 12, 13, 1921,
Section Ophthalmology, Otology and Rhino-Laryngology.
pressure was normal and all other physical signs
negative pertaining to a beginning sclerosis.
Therefore I hesitate to say but somewhat of
the belief that some men use the terms arterio-
sclerosis and high blood-pressure synonymously,
but one should keep in mind the first is a path-
ological entity, the latter the result.
For we ha\ e all seen cases where there was
marked hypertension and no changes in the fundi,
while in some of the veri' advanced changes there
was no hypertension.
Therefore I think the internists should be fa-
miliar with these changes such as, increased tor-
tuosity of the retinal vessels broadening of the
light streak. The cupping of the veins as they
cross the sclerosed arteries with more or less of a
varicosity of the distal end.
The oedematous condition of the retina with
irregular shaped hemorrhages and occasional
exudates.
The cedematous condition is recognized by a
fluffy appearance of the retina. The hemor-
rhages as a rule are near a blood-vessel.
It has been shown recently that senile chor-
oiditis is simply due to the gradual shutting off
of the blood supply around the macule due to
arteriosclerosis.
In cases where the pigment has been absorbed
the choroidal vessels may show a marked tor-
tuosity, just why some cases show more change
in the retinal vessels and others in the choroidal
vessels is not known.
There is no questioning the fact the eye is one
of the most important organs from the standpoint
of diagnosis.
Therefore I feel that all cardio-vascular renal
or nervous cases should have a proper ophthal-
moscopic examination. As quite often an unde-
termined diagnosis may be cleared up.
I recall a case of about one year since a man
age sixty-five consulted me complaining of
blurred vision and was unable to get a correction
which would clear up his poor vision. The
ophthalmoscopic examination showed advanced
arterio-sclerosis. He stated he had never been ill
and enjoyed the best of health at that time.
He was advised to consult an internist who
found marked increased vascular tension along
with chronic interstitial nephritis. This patient
died in less than thirty days from apoplexy.
As has been stated we have all seen cases of
sclerosis of the retinal vessels when clinically
there was no general manifestations of a general
sclerosis. Although men like Hertel and others
with both clinical and pathological evidence that
VoL. XII, No. 4]
Journal of Iowa State Medical Society
137
the retinal vessels pre-supposes with certainty a
similar state in the cerebral arteries but not the
reverse in a number of cases of pronounced vas-
cular disease in the brain the ophthalmoscopic
condition was nonnal. The retinal arteries are
furthermore end arteries just as are the cerebral
blood-vessels which supply the basal ganglia and
are equally exposed to increased blood-pressure
in the internal carotid artery. Raehlmann w'hom
we owe the first careful compilation of this sub-
ject relative to general arteriosclerosis found in
about 50 per cent of his cases, changes in the
retinal vessels. In general according to Raehl-
mann, Friedenwald, Hertel and others changes in
the retinal vessels occur in those cases of general
arteriosclerosis in which the large cerebral ar-
teries are particularly involved. Arteriosclerotic
changes may affect either the arteries, or the
veins or both and only a small area involved.
It is this class of cases one should be on the
lookout for and be seen by the internist for it is
only a question of time until in all probability
symptoms will develop.
I had this impressed upon me while in the ser-
vice, as in our routine work of refraction an
ophthalmoscopic examination was made, and
often the question was asked did he have a fundus
examination when he had his last examination?
It was surprising the amount of negative answers.
Microscopic changes in the retinal vessels of
advanced arteriosclerosis have been found, which
could not be observed wdth the ophthalmoscope.
Functional disturbances in the retina does not
occur until vessel-closure exudates, or hemor-
rhages have taken place.
The certain diagnosis of arteriosclerosis of the
retinal arteries, the vessel w'alls must be outlined
with white lines and distinctly thickened, the
lumen must be narrowed up to the point of
ischemia and complete obliteration. In the ear-
lier stages the diagnosis can only be made when
arteriosclerotic changes have led to arterial oc-
clusion through thrombosis, as in the picture of
closing of the central artery, when the above is
found one need not hesitate to assert himself as
to the prognosis of the case.
Relative to prognosis, I only wish to quote Gei's
reports on seventeen cases of sclerosis of the
retinal vessels ; all seventeen cases died within
four years.
Vascular changes in the retina, due to syphilis,
have not the same gross prognostic significance
as the arteriosclerotic changes have.
Retinal hemorrhages, if they are not due to
local diseases or abnormal blood conditions, occur
when the vessel walls are brittle. These vessel
changes may not be recognizable with the oph-
thalmoscope, although those isolated hemorrhages
which occur in the macular region do not seem to
have the same general significance as the hemor-
rhages which occur elsewhere in the retina.
This also aiijdies to syphilis. Albuminuric
retinitis aside from the usual picture in this dis-
ease, we may find superimposed isolated retinal
hemorrhages which are due to a sclerosis. In
this condition, according to Gei’s apoplexies are
to be expected and in the cases he followed up
they always occurred.
Thrombosis of the veins occurring in cases
wdth albumin in the urine should be differentiated
from cases of albuminuric retinitis, and isolated
retinal hemorrhages occurring in nephritis, as this
is important when it comes to prognosis.
In diabetic retinitis, w’e find more frequently
definite changes in the vessel walls, this no doubt
is due to the increased vascular tension which oc-
curs in a large percentage of these cases.
In conclusion I wish to mention vascular
spasm.
It seems to me this is a phase of the subject that
is too often passed by and not the proper signifi-
cance given it.
Just recently I had an interesting experience, a
w'oman, married, age thirty- five, referred to me
on account of sudden obscuration of vision right
eye, which would last from a few seconds to a
minute or so. Fortunately I observed her in one
of these attacks and observed a marked constric-
tion of the retinal vessels, otherwise no fundus
changes. Vision right 20/30, left 20/20. She
was referred to an internist who found a moder-
ate increased vascular tension with a low grade
nephritis.
REFERENCES:
Mahomed, F. A. — On Chronic Bright’s Disease and its Essen-
tial Symptoms. Lancet, 1879, i, 46-47, 76-78, 149-1.50, 261-263,
399-401, 437-438. Some of the Clinical Aspects of Chronic
Bright’s Disease. Ciiy’s Hosp. Re., 1879, xxiv, 3.s, 363-436.
Moore, R. F. — The Retinitis of Arteriosclerosis, and its Relation
to Renal Retinitis and to Cerebral Vascular Diseases. Quart.
Jour. Med., 1916-1917, x 29-77.
Leber, Th. — Die Netzhauterkrankungen bei Nierenleiden. In:
Graefe-Saemisch Handbuch. 2te Aufl. Leip., Englemann, 1915
V. 7, pages 803-945.
Adams, P. H. — .Arteriosclerosis and the Eye. Brit. Joui.
Ophthal. 1920, iv, 297-318.
Bergemann, II. — .\ugenerkarankungen bei Nierenentzundung.
D.eutsch. Med. Wchnschr., 1918, no. 19, 520-522.
Lollert, V. and Finger A. Zur Frage der Ritininitis Nephritica
W'ie. klin. Wchnschr., 1918, xxxi. 77-781.
Brav, A. — Ocular Complications in Renal Disease: Their Diag-
nostic and Prognostic Value Archives Diagnosis, 1918, xi, 29.
Fox, L. W'. — -Arteriosclerosis and the Eye, New York Med.
Jour., 1919, cxi, 1921.
Kershner, W. E. — Ocular Internal Hemorrhage in Case if
Bright’s Disease. -Amer. Jour. Ophthal., 1919, ii, 594.
Clapp, C. A. — -Arteriosclerosis and its Diagnosis from Ocular
Standpoint. -Archives Diagnosis, 1919, xi, 257.
Stillson — Eye in .Arteriosclerosis. Northwest Medical 1916,
XV, 300.
Slocum — Nephritis and Changes in the Eye. Jour. -Amer. Med.
-Ass’n., 1916, Ixvii.
138
Journal of Iowa State Medical Society
[April, 1922
Allerman, L. A. W. — The Retinal Symptoms of Vascular
Degeneration. American Medicine, 1904, vol. vii, 304.
Knapp, Arnold — The Prognostic Significance of Changes in
the Retinal Vessels. Medical Record, 1915.
Thompson, P. H. — Boston Medical and Surgical Journal. Vol.
clxxv. No. 5, pp. 161, 1916.
Woodruff, F. A. — Changes in the Retina and Retinal Vessels
as an Indication of Lesions in Heart and Blood-vessels. Medi-
cine, vol. xii. No. 3, pp. 167-173, 1906.
PXELAIOCOCCUS PERITONITIS*
\Tctor F. ^Iarshall, B.S., ]\I.D., F.A.C.S.,
Appleton, Wisconsin
The surgeon still continues to meet with some
cases of peritonitis in his practice, although the
number met with each year becomes lessened.
The number met with by any individual surgeon
of pneumococcus peritonitis up to the present
time has been limited. During the years 1918 and
1920, two cases of pneumococcus peritonitis have
come under my observation and which furnish
the basis for the following remarks.
Case I. Dorothy G., age two and one-half years,
entered St. Elizabeth Hospital, !March 15, 1918, re-
ferred b}- Dr. Finney. Her previous history was
negative excepting that she had recovered from a
lobar pneumonia which had its onset three weeks
previously. The temperature had been normal for
more than a week, and three days previous to her
entrance into the hospital she complained of ab-
dominal pain; some vomiting and diarrhea were
present. The temperature upon her admission was
104 degrees F., the pulse 140. Upon examination the
right rectus revealed a slight rigidity with the evi-
dence of a moderate tumefaction subumbilical and
to the right. The blood revealed a leucocj-tosis of
28,000. A diagnosis of a perforated appendix was
made. Upon opening the abdomen a seropurulent
fluid, odorless, of a yellowish-green color appeared.
The coils of intestines were injected. Fpon bringing
the appendix to view I was surprised to find it nor-
mal in appearance. It was deemed advisable to re-
move it as the patient was not subjected to any
marked additional danger in its performance. Some
of the material was taken for bacteriological examin-
ation. Tube drainage was used and the usual treat-
ment for peritonitis was instituted, i. e., Fowler po-
sition and proctolysis. The first few days of the pa-
tient’s convalescence were somewhat stormy and ex-
cepting for a spell of cr3ung a week later when an
evisceration occurred and which necessitated resuture
of the abdominal wall, complete recover}- ensued.
My laboratory reported an unmixed presence of
pneumococci organisms which agreed with the re-
port of an examination of the same material sent to
the State Hygienic Laboratory at Madison.
Case II. Anita V., Medina, Wisconsin, age five,
referred by Dr. Ott, entered St. Elizabeth Hospital,
•Read before the .■\nnual -\ssembly, Tri-State District Medical
Society.
January 18, 1920. Her health had been normal up to
four days previous to the onset of her present illness.
The illness began suddenly with a high temperature,
vomiting, frequent bowel movements and pain in the
lower abdominal region.
Upon examination the little patient was found to
be intensely ill. The temperature was 105.4 degrees
per rectum, pulse 150, and evidences of a severe
toxemia were present, as manifested by a slight cyan-
osis and some dyspnea. The abdomen was not
markedly rigid, yet there was present a right sub-
umbilical tumefaction. The leucocyte count was
40,000 with a marked preponderance of polymor-
phonuclears. It was evident that a peritonitis existed
but wdth an obscure origin. The present symptoms
were incompatible with those produced by a perfor-
ation of an intra-abdominal viscus. A peritonitis of
pneumococcus origin was thought of for the inform-
ation obtained in our experience with the previous
case was still vivid in our memory. ,\n abdominal
exploration was deemed advisable, and to which she
was subjected. Upon opening the abdomen a marked
amount of seropurulent fluid, yellowish-green in
color and odorless appeared. It was then plainly
evident that we were dealing with the same condi-
tion as in the previous case reported. Some of this
exudate was taken for bacteriological examination.
The reports of the State Hygienic Laboratory by
Dr. Stovall and my own laboratory were agreed as
to an unmixed strain of pneumococcus. It was not
typed. This little patient had a most stormy con-
valescence, but she finally recovered and was dis-
missed from the hospital March 27, 1920. During
this period it was necessary to make a suprapubic in-
cision to give exit to an accumulation of pus which
developed in that region. A few days later a pneu-
monia appeared in the right lower lobe which re-
solved. Following, an acute nephritis appeared which
subsided after a week. Metastatic abscesses then ap-
peared in various parts of the body which were in-
cised and the contents evacuated. An autogenous
vaccine was made and used assiduously, but with
apparently no avail. The condi.tion of the little pa-
tient was truly alarming for it appeared that she
would not recover. Her emaciation was most ex-
treme. As a final resort it was thought to use helio-
therapy, “With nothing to lose and everything to
gain.’’ The little patient was therefore subjected to
the sun’s rays in a nude condition and with the most
happy results for within a very few- days con-
valescence appeared and her full recovery ultimately
ensued.
There is no doubt that this disease has a clini-
cal entity which is characteristic.
Summary of cases reported:
Von Brunn in 1903, collected fift}--seven cases
of pneumococcus peritonitis in children and fif-
teen in adults; by 1906, Annand and Bowen state
ninety-one cases were recorded mostly in chil-
dren. Additional cases to this list are recorded
by C. R. Belgrano, Reforma. Med. April 7, 1917 ;
VoL. XII, No. 4]
Journal of Iowa State Medical Society
139
four cases by Abt. A. L, N. Y. M. J. April 28,
1917; one case by Meredith, E. W., P. M. J. 1918;
one case by MacWilliams, H. H., Brit. M. J.
February 22, 1918; one case by Edwards S. R.
and Noble F. B., J. Ind. M. A. April 1, 1920; and
the two cases occurring in my own practice, mak-
ing a total of 102 cases.
Syms in a careful review of the literature of
pneumococcus peritonitis states :
“It is. a disease particularly affecting children.
Up to the fifteenth year of age it is three times as
prevalent as after that period.
“It is much more frequent among girls than
among boys in the proportion of three to one.
“It may occur (1) as the only local manifesta-
tion; (2) as a sequel to some previous site of
pneumococcus infection, i. e., lung, pleura, peri-
cardium, ear, etc., or (3) as a part of a general
septicaemia in which other organs are simultane-
ously involved.
“It is found in two varieties: (1) As a dif-
fuse general peritonitis and (2) an encysted or
localized process. Some claim that these two
conditions represent stages of the disease, and
that there is always a diffuse peritonitis at first
which later becomes localized by intestinal adhe-
sions. Others (Michaut) claim that there are
two distinct varieties of the diffuse.”
Upon the other hand some writers contend
these varieties are produced by a difference in
the virulency of the same organisms, and so are
distinct types.
Again quoting Syms ;
“The first stage is that of toxaemia, the child
being overwhelmed by the poison. There is a
great depression and the patient is much more
ill than the abdominal symptoms would indicate.
“The second stage is characterized by ab-
dominal symptoms ; the signs of advancing peri-
tonitis.
“The third stage is characterized by a continu-
ance of the signs of peritonitis with effusion.
During this period there is often an abatement
of the active signs of toxemia. The temperature
may fall and the patient may seem decidedly less
ill. If the pus has become encysted or localized
there will be signs of intra-abdominal abscess or
abscesses. The abdomen becomes distended ; this
particularly relates to the lower part of the abdo-
men, for the disease is usually subumbilical.
When loculation has taken place there is usually
an irregular swelling of the abdomen, one side
being affected more than the other. One char-
acteristic of the disease in its late stages is the
protrusion of the umbilicus and its final perfor-
ation. There have been many reports of the dis-
charge of pus through the umbilicus and this
seems to be a condition almost peculiar to the
disease. The discharge will be of the character-
istic greenish-yellow, serofibrinous, odorless pus.
“Hector Cameron states his position very
clearly when discussing the question of treatment.
He regards the diffuse form of peritonitis as be-
longing to the early stage and not as representing
a distinct type of the disease.
“Whether diffuse pneumococcus peritonitis is
an early stage or a special form of the disease, the
fact remains that it represents the period or con-
dition of the utmost gravity. Annand and Bowen,
analyzing ninety-one cases that had been bac-
teriologically studied and satisfactorily reported,
found in the diffuse form a mortality of 86 per
cent. In the same series of cases in the encysted
form there was a mortality of but 14 per cent.
“In the same article Annand and Bowen de-
scribe sixteen cases which had occurred in the
East London Hospital for Children. All of the
sixteen of these cases were of the diffuse variety.
Death resulted in all sixteen, showing a mor-
tality of 100 per cent.”
Etiology — Abt states: “The disease represents
a specific infectious process, but the route is diffi-
cult to establish. Two groups are recognized:
(1) the primary or idiopathic; (2) the secondary,
in which the peritonitis is subsequent to some pre-
existing pneumococci lesion elsewhere, pleuro-
pneumonia being the most common, and otitis
media the next distinctive type is justified, al-
though this path of invasion is obscure.”
Fishbein in his clinical article on “The Bac-
teriology of Peritonitis” states, “The anatomical
character of the inflammation does not bear any
relationship to the nature of the primary lesion
when such exists, nor does it seem to be influ-
enced by the presence of various bacteria alone
or in combinations of various kinds. Various
bacteria or the same bacteria cause the same or
different forms of peritonitis.”
Symptomatology- — The disease presents a clini-
cal picture that is characteristic and which should
lead to diagnosis in the most primary cases. Its
characteristic signs are sudden onset, extreme
toxemia, vomiting and diarrhoea, very high tem-
perature, and a very high leucocytosis with a
high polymorphonuclear count. There is a not-
able absence of local pain, local tenderness, and
local rigidity as compared with appendicitis or
perforation peritonitis. Some have described the
abdomen as having a “doughy” feel. x\dded to
all this is the pneumonia aspect, cyanosis, slight
dyspnoea, great depression, etc.
Diagnosis — A correct diagnosis of this condi-
COME HELP TO MAKE THE ATTENDANCE 1000
140
Journal of Iowa State AIedical Society
[April, 1922
tion is all important. We must decide whether
the case is or is not one of pneumococcus peri-'
tonitis and if it is pneumococcus whether it is
diffuse or encysted as operation is not indicated
in the former, but decidedly so in the latter. The
important points in the diagnosis are sudden on-
set, with no prodromal symptoms, the presence
of an extreme toxaemia and depression. It is
often ushered in with a chill. High temperature
is characteristic with a very high blood count,
from 20,000 to 40,000. Diarrhoea may appear
early or be developed in a day or two. Peri-
tonitis with diarrhoea should always make one
suspicious of pneumococcus. Early drowsiness,
restlessness, and delirium point to the involve-
ment of the nervous system from the intense
toxaemia, a condition we frequently find in
pneumonic affections of the lungs. In pneumo-
coccus peritonitis the constitutional symptoms
overshadow the abdominal findings in contradic-
tion to the early stages of a perforative appen-
dicitis. There is no distinct point of tenderness.
The abdomen has a peculiar “doughy” feel. The
presence of fluid may be determined and is us-
ually subumbilical and unilateral. A blood ex-
amination is of the utmost importance as it may
reveal a bacteraemia.
J. Dubs states : “Pneumococci have been found
in the urine even from the earliest phase of the
peritonitis.” Upon opening the abdomen evidences
of a peritonitis are found with no local point of
origin. The appearance and character of the exu-
date consisting of an odorless, seropurulent, yel-
lowish-green color, containing a great amount of
fibrin is significant.
Treatment — Most operators are agreed that an
expectant treatment is to be pursued in those
cases of pneumococcus peritonitis of the diffuse
variety ; this treatment should be open air, helio-
therapy, supportive, proctolysis, and the Fowler
position.
Operation is indicated and advisable where the
exudate has become loculated; and where the ex-
treme toxaemia and dejiression have subsided.
The dictum of J. B. IMurphy still holds good,
“Where there is pus, evacuate — get in quickly and
out hurriedly.” Serum treatment has a legit-
imate use here as elsewhere in the body in pneu-
mococci peritonitis.
Conclusions
1. Pneumococcus peritonitis is a disease of
childhood affecting principally girls.
2. Its onset is sudden, manifested by a severe
toxaemia, and a very high mortality.
3. Two forms are distinguishable (1) diffuse.
(2) encysted or loculated.
4. The symptomatology is characteristic.
5. Treatment is (1) expectant and suppor-
tive, (2) surgical.
BIBLIOGRAPHY
-\bt. I. A. : Pneumococcic Peritonitis in Infancy and Child-
hood. New York, M. J. 105:769, -\pril 28, 1917.
Annand. W. F. and Bowen, \V. H. : Pneumococcic Peritonitis
in Children. Lancet 1906, 1:1591.
Belgrano, C. R. Reforma Med. Napoli, April 7, 1917.
Berard and Colombet: Peritonite a pneumocoques chez I’adulte.
Lyon med. 117:380, 1911.
Brunn, M. von: Die Pneumokokkum Peritonitis. Beitr. Z. klin.
Chir. 39: 57, 1903.
Cameron. H. C. : Pneumococcal Peritonitis in Children. Brit.
T. Child. Dis. 9:264, 1912.
Campbell, W. F. : Pneumococcus Peritonitis. Med. Times 42:
337. 1914.
Dickinson, C. K. : Pneumococcic Peritonitis. J. M. Soc. New
Jersey. 7:244, 1910-11.
Dubs, J.: Differential Diagnosis of Acute Appendicitis in
Children. Schweizeriscbe Medicinische wochenschrift, Basil,
-\pril 29, 1920. 50 No. 18.
Edwards, S. R. and Noble, F. B. : Case of primary peritonitis.
J. Indiana M. April, 1920.
Fishbein, Morris: Contribution to tbe Bacteriology of Peri-
tonitis. with special reference to Primary Peritonitis. Am. Jour.
•Med. Sc. October, 1912.
Green. N. W.: Idiopathic Peritonitis, Probably of Pneumo-
coccus Origin. Anna. Surg. 60:387, 1914.
Hafers, E. H. : Ein Beitrig zur abgekapselten Form der Pneu-
mokokken-Peritonitis. Deutsche Zeischr, f, chir. 137:244, 1916.
Hallez, G. L.: La Peritonite a pneumocoques chez les enfants
du premier age. Nourisson, 3:138, 1915.
Tensen, J. : Die Pneumokokken Peritonitis. Arch f. klin.
Chir. 60:1134; 70:91. 1903.
Kahn, L. M.: Pneumococcus Peritonitis, New York, M. J.
100:1166, 1914.
L. C. P. : Peritonite a Pneumocoques. J. de. med. et. chir.
prat. 83:582, 1912.
Ledoux. : Deux observations de peritonite pneumococcique
primitive. Rev. med. d. 1. Franche-Comte. 20:1, 1912.
MacWilliams, H. H. : Pneumococcal Peritonitis in adult. Brit.
M. J. 1919. 1:216.
Meredith. E. W. : Pneumococcus Peritonitis. Penn. M. J.
21:556. 1918.
Mathews, F. S. : Pneumococcus Peritonitis. Ann. Surg. 40:698,
1904.
Michaut, C. : Contribution a I’etude de la peritonite a pneumo-
coques chez. I’enfant. Paris Thesis, 1901.
Moro: Zur Statistik der pneumokokken Peritonitis. Deutsche
med. Wchnrschr. 43:288, 1917, also Munch. Med. Wchnschr.
64:846, 1917.
Jloslein. : Pneumokokken Peritonitis. Deutsche med.
Wchnschr. 38:1765, 1912.
Nobecourt: Peritonite a pneumocoques. Rev. Gen. de din.
et de therap. 24:115. 1910.
Noon, C. and Moreton, A. L. : Acute pneumococcal Peritonitis.
St. Barth Hosp. Rep. 48:137, 1913.
Salzer, H. : Ueber Diplokokken peritonitis. .\rch. f. klin.
chir. 98:993. 1912.
Steblin, Kaminski, E. E. : Ueber Pneumokokken Peritonitis.
Deutsche .Aertze Itg. 1909:319, 342.
Stone. H. E. : Pneumococcal Peritonitis. Bull. Johns Hopkins
Hosp. 22:219, 1911.
Syrnpson, N. S.: Pneumococcal Peritonitis occurring during
Parotitis without lesion being found in abdomen. Indian. M.
Gaz. 48:107, 1913.
Syms, P. : Pneumococcus peritonitis. Ann. Surg. 67:263, 1918.
Discussion p. 247.
Verbizuer. A. de: Peritonite a Pneumocoques chez I’adulte.
Toulouse med. Ser. 2. 15:1, 1913.
Wetzel, E. : Ueber ein fall von Peritonitis pneumococcica ex-
trangenitalen. Ursprunge bei einer Puerpera. Munch, med.
Wchnschr. 62:109, 1915.
Wharton, N. R. : Pneumococcic Peritonitis. Tr. Philadelphia,
Acad. Surg. 13:80, 1911.
Williams, W. R. : General Suppurative Pneumococcus Peri-
tonitis. Med. Rec. 87:711. 1915.
Woolsev. G.: Pneumococcus Peritonitis. Med. and Surg. Rep.
Presbyterian Hosp. 9:507, 1912, also Am. J. M. Soc. 141; 864,
1911. '
Zimmerman: Peritonite pneumococcique. Rev. med. de. la
Suesse Rom. 34:435. 1915.
VoL. XII, No. 41
Journal of Iowa State Medical Society
141
DIAGNOSIS AND TREATMENT OF IN-
FANTILE PARALYSIS*
Arch F. O’Doxogiiue, ]\I.D., Sioux City
In surgery as in other fields an ounce of pre-
vention is more valuable than a pound of cure.
Ninety per cent of the deformities following in-
fantile paralysis are wholly preventable. I there-
fore am going to take the liberty of recalling to
your attention the present methods of diagnosis
and treatment of this disease.
I will not go into history, etiology or prophy-
laxis more than to note that the disease was fir^t
recognized as an entity by Jacob von Hiene in
18-40, and its epidemic character demonstrated by
Medin in 1887. The causative agent has been
well proven in recent years by Simmon Flexner
as a filtrable ultra-microscopic organism which
usually gains entrance to the body through the
nose and throat, is found in the lymph channels,
the spinal fluid, and the gray matter of the brain
and cord, but not in the circulating blood. The
infectivity has not yet been definitely determined
but from recent experiments it would seem that
the danger of infection has practically ceased
within six weeks of the first symptoms. From
the standpoint of prophylaxis the experiments of
Amoss and Taylor tend to show that during epi-
demics or after exposure the danger of contract-
ing the disease is considerably lessened by sprays
and gargles. The pathology in the acute stage is
a dry hyperemia of the pia archnoid which under
the microscope shows small round cell infiltration
about the meningeal vessels and extending into
the fissures of the cord. On section of the cord
proper the cut surface bulges, appears moist and
with the gray mater so hyperemic as to resemble
a red letter H, although in less severe cases the
redness is limited to the anterior horns. On mi-
croscopic examination there is a small round cell
infiltration throughout the entire myelin tissue
and although the gray matter is more affected
than the white there is no portion of the cord
which entirely escapes. The motor ganglion cells
of the anterior horns are affected by the intense
infiltration and later in the disease they disappear
and are replaced by glia tissue. Ganglion cells
which have necrosed never regenerate although
those less seriously injured undergo partial or
complete restoration. The cervical and lumbar
swellings of the cord are the areas chiefly af-
fected and the actual destruction of cells is us-
ually limited to the motor ganglion cells in the
anterior horns. While ordinarily the cord is the
•Presented at the Twenty-si.xth Annual Session, Sioux Valley
Medical Association, July 20 and 21, 1921, Sioux Falls, S. D.
most affected, in fatal cases lesions of the
medulla, pons, cerebellum, and even cerebrum
sometimes exist. In the chronic stage the cord
pathology consists of areas of scar tissue and
atrophy in the anterior horns, but in the chronic
stage pathology is not limited to the cord but
affects also the muscles, tendons, bones and
joints. Muscular changes consist of a rapid
atrophy and degeneration with apparent fusion
of fibers so that the individual ones cannot be
differentiated, and in long standing cases the
muscle is changed to an apparent small band of
connective tissue. The tendons atrophy in size
and power due to disuse, the bones show osteo-
porosis, become delicate and brittle, and do not
grow either in length or thickness to correspond
to the sound side; and the joints become relaxed,
unstable, abnormally mobile, and easily subject to
subluxation and dislocation.
The symtomatology may be somewhat compli-
cated but in the usual case after an incubation
period varying between two days and two weeks
irritability, malaise, weakness, dizziness and ver-
tigo appear, attended by more or less ataxia which
is accompanied by frequent falls. This ataxia is
present in most cases and most patients will give
a history of a fall or falls with subsequent paraly-
sis, blaming the paralysis on the fall when as a
matter of fact the fall was due to the paralysis.
The onset is usually accompanied by fever, rapid
pulse and respiration, gastrointestinal irritability
and symptoms of cord disease, manifested the
first and second day by headache, tremors, in-
coordination, ataxia, convulsive movements, stra-
bismus, opisthotonos, hyperesthesia of the ex-
tremities, and any or all of the other symptoms
of meningeal irritation. The reflexes are usually
exaggerated at the onset, to disappear entirely
later in the disease as the paralysis develops.
The paralysis is discovered in severe cases after
the subsidence of the stormy initial symptoms.
On the other hand, the onset may be so mild that
it is unnoticed, as in a case of a child who retires
in a normal condition and is discovered to be
paralyzed in the morning. However in most of
these mild cases, one will get the history of one or
more falls the preceding day showing that ataxia
at least has been present. The paralysis is con-
fined to the motor system alone and advances
with great rapidity, usually reaching its height
in a few hours.
I wish to point out some of the peculiarities of
the paralysis in poliomyelitis. First the paralysis
is sudden in onset with a history of a fall or
falls which in themselves were not sufficient lo
produce a cord lesion. Second the paralysis is
142
Journal of Iowa State Medical Society
entirely motor in type, and almost never follows
the distribution of any one nerve or nerve trunk.
Third, the fingers and toes are usually the last to
be affected, and entire leg for instance, lying
helpless except that the patient can slightly move
his toes. Fourth, the patient is usually a child
and children are not often attacked by the other
common cord diseases. Diagnosis is easily ar-
rived at, for it will be seen that a motor paralysis,
not following the distribution of any nerve, or
nerve trunk and without loss of sensation is al-
most invariably infantile paralysis. The early
diagnosis is very important to the patient for the
immediate application of the proper treatment
will greatly increase his chances of becoming a
useful and self-supporting member of society.
The treatment of infantile paralysis divides it-
self into the treatment of its stages, the acute, the
convalescent and the chronic.
The acute stage is that from the onset to the
disappearance of the tenderness and calls for the
same treatment that any other acute disease of
childhood should receive.
The convalescent stage begins with the cessa-
tion of tenderness and extends usually for about
two years, during which period, we may expect a
progressive improvement in strength and func-
tion under conservative treatment, and during
which time operative interference should not be
carried out, except the lengthening of shortened
tendons in selected cases. The treatment of the
convalescent stage attempts to restore voluntary
muscular power and to prevent deformity. The
greatest single factor in the treatment of para-
lyzed muscles is rest, in the position of neutral
muscle pull so that the paralyzed muscle will not
be subjected to a constant stress by being opposed
to healthy muscles. This rest is best secured by
comfortable splints or light plaster casts. Splints
are to be preferred, for with removable splints
we are able to carry out other valuable therapeutic
agents.
In the average untreated case a paralyzed mus-
cle opposed to a healthy muscle becomes stretched
and attenuated, while the opposing healthy mus-
cle becomes contracted and shortened. A com-
mon example is the shortened tendo Achilles with
a consequent equinus following paralysis of the
tibialis and peroneus groups. All such contrac-
tures are wholly preventable and mean that the
child has not received proper care.
The most valuable factor next to rest, is pains-
taking thorough daily massage, accompanied by
passive motion. As the paralyzed muscles begin
to resume their function, guarded active move-
ments should gradually supplant the passive ex-
[ April, 1922
ercises, great care being taken to guard against
fatigue.
Yet another valuable adjunct in our treatment
is heat, which should be applied for several min-
utes daily just before massage. The form of
heat applied is not of paramount importance, al-
though the sun bath is preferable, electric baths,
hot water bottles, etc., will serve the purpose ad-
mirably. The patient should receive heat treat-
ments just prior to massage, because the heat badi
will flush the muscles with fresh blood.
Electricity in its various phases, faradism, gal-
vanism, high frequency, diatheramy, sinusodial,
etc., have been much lauded at different times.
We cannot say that these methods are worthless,
but carefully controlled experiments would seem
to cast a doubt on their positive action and cer-
tainly all the methods above are of infinitely more
value. However, if the means of applying these
currents are at hand, it surely would do no harm,
and may do some good to use them.
In summing up the treatment of the con-
valescent stage I wish to emphasize and reem-
phasize the great importance of rest in a neutral
position. By this means not only are deformi-
ties prevented but a muscle temporarily para-
lyzed by the inhibition of its lower motor neuron,
is not so stretched and weakened that if later the
neuron is again able to assume its function, it
would find not a few stretched, anemic, muscle
cells to receive its impulse, but would find a
muscle at least near normalcy. Massage, careful
exercises, heat, and electricity, have their places
but of greater importance than all of these com-
bined is rest.
The treatment of the chronic stage is mostly
operative and is of two types, operations for the
correction of deformities, which have developed
as a result of neglect during the convalescent
stage, and, second, operations designed to im-
prove function. Of the operations to correct
deformities, the various tendon lengthenings such
as Steindler’s operation for pes cavus, lengthen-
ing of the tendo Achilles, lengthening of the ham-
strings, Soutter’s operation for relief of contrac-
ture of the thigh, etc., are the most common.
Plastic bone operations are not often needed to
correct deformity although in a bad club foot, pes
calcaneus, etc., a bone plasty is sometimes essen-
tial.
The operations to improve function consist of
the tendon transplants and the arthrodesis of
joints. Of the several score of tendon trans-
plants in vogue some years ago, only a few stood
the test of time, and of these, probably the most
satisfactory, is the physiological transplant of the
VoL. XII, No. 41
Journal of Iowa State Medical Society
143
healthy tendon of the extensor longus hallucis for
the paralyzed tendon of the tibialis anticus to
correct a paralytic drop foot.
The arthrodeses attempt to stabilize flail
joints. The ones most useful are, arthrodesis
through the ankle, arthrodesis of the wrist, to
counteract a drop hand, and arthrodesis of the
shoulder, to allow unparalyzed scapular muscles
to supplant paralyzed humeral groups. It will
quite often be found that both types of operation
will be necessary on the same patient. In such
cases the operation to correct deformity and the
operation to improve function may sometimes be
done at the same time, but it is usually advisable
to first correct the deformity, following this by
several months of conservative treatment. Not
uncommonly after this procedure the operation
to improve function is unnecessary.
In conclusion I wish to repeat :
1. That poliomyelitis is a disease of the cen-
tral nervous system characterized clinically by a
motor paralysis not following the distribution of
any nerve trunk.
2. That its early diagnosis is not difficult and
is essential to the future well being of the patient.
3. That the most important weapon in its
treatment is rest of the paralyzed muscles.
4. That under proper supervision we will
have few deformities, and we will further have a
surprisingly large per cent of apparently para-
lyzed muscles again assuming some degree of
function.
306 Trimble Bldg.
ACUTE INFECTIONS OF THE
ABDOMEN*
D. W. Ward, M.D., Oelwein
It has been truthfully stated that there is noth-
ing new under the sun, and surely, considering
the numerous articles written daily by the many
contributors to medical and surgical literature, it
would seem that all the important points on ev-
ery subject had been sufficiently touched and re-
touched as to leave no more room for discussion ;
and it certainly remains for only a very few to be
able to present anything new in his line of en-
deavor. However, it is equally true that in medi-
cal and surgical practice many well known points
are so important, and regardless of importance so
frequently disregarded or overlooked, that we can
still profit by going over old ground.
So it will be the purpose of this paper to go
over a little old ground and briefly emphasize
some well known points in connection with the
subject of “Acute Abdominal Infections,” be-
cause I believe that in this class of cases more
than in any other, mi.stakes in diagnosis and treat-
ment are frequently made on account of the fail-
ure to apply certain well known and established
principles rather than a lack of knowledge of
these principles, and on account of failure to ap-
ply this knowledge at the proper time.
The etiolog}' and pathology will not be con-
sidered, but just a few points in the diagnosis and
treatment of these conditions will be discussed.
Acute abdominal infections may be divided into
two groups or classes, viz ; cases that are pri-
marily abdominal infections, such as appendicitis,
acute cholecystitis, pelvic infections, etc., and
cases of infection of the abdominal cavity coming
on secondary to or caused by other diseases, such
as perforating typhoid ulcers, gastric and duo-
denal ulcers, etc., where perforation and injection
of infectious material into the abdominal cavity
has supervened during the course of another dis-
ease. More rarely cases are now and then seen
such as phlegmonous gastritis. Perforations of
the uterus following abortion and curettages are
not uncommon factors in producing acute ab-
dominal infections.
The most important point for emphasis is that
in all these cases of either class, but more es-
pecially of the second, time is invariably the most
important factor of all in the successful treat-
ment. In no other class of cases is it more im-
portant for the surgeon to be alert and ready to
weigh the minutest evidence in his decision as to
diagnosis and treatment. The mortality in such
cases as perforating typhoid ulcers and gastric
and duodenal ulcers depends directly in an almost
definite ratio to the length of time from the on-
set to the time of surgical interference.
While careful consideration of the cardinal
signs in diagnosis of acute abdominal infections
usually leads to correct early diagnosis in the
average case, in some cases this is by no means
easy, and the extreme necessity for correct early
diagnosis and treatment makes some of these
cases most trying. However, failure to properly
diagnose these cases early is usually due to fail-
ure to recognize well known symptoms, and by
far too often even yet, is the surgeon called upon
to operate upon a case of purulent peritonitis, as
much as a week or ten days after a ruptured gan-
grenous appendicitis that should have been noth-
ing more than an acute appendicitis.
‘Within the last year I was called in consulta-
tion to see a child of seven or eight years who was
moribund, that the physician had been treating
•Read at the Austin Flint-Cedar Valley Medical Society, Clear
Lake, Iowa, July 19, 1921.
Secure Your Hotel Reservations at Once — For Hotels, See Advertising Pages iv, vi, and viii
144
Journal of Iowa State Medical Society
[April, 1922
with enemas and purgatives. This little unfortun-
ate patient died about one-half hour after I en-
tered the house, an autopsy revealed an abdomen
literally filled with pus from a ruptured gan-
grenous appendix. It is absolutely certain that
careful abdominal examination two or three days
previously would have revealed a rigid right
rectus muscle and local tenderness enough to
make a diagnosis of appendicitis in time for
proper surgical treatment. The disappearance
of pain, as is often the case in some of these cases,
blinded the physician to the necessity of a careful
abdominal examination until the case was incur-
able.
We should think of most cases of purulent
peritonitis as preventable diseases, and they are
preventable in the proportion to the watchfulness
and observation of cardinal symptoms on the part
of the attending physician, rather than the sur-
geon, who usually sees the cases after the diagno-
sis has been made by the attending physician, and
successful surgical treatment depends directly on
the time the diagnosis has been made, hence the
importance of a knowledge of these signs on the
part of the general practitioner as well as the
surgeon. It is just as negligible and fatal to fail
to carefully examine the abdomen of every pa-
tient, no matter how young or how old, in which
there are suggestive symptoms relating to the ab-
domen as it is to fail to carefully examine the
chest of a patient who has a persistent cough to
ascertain the presence or absence of tuberculosis.
Yet this is of too frequent daily occurrence. It
is not the typical case that we should be on the
lookout for, but rather, the atypical ones.
The first symptom of an acute infection of the
abdomen is usually pain. This is usually diffuse,
gradually becoming local over the site of the in-
flammation. Then follows nausea and vomiting,
rise of temperature, rapid pulse, coated tongue
and later distressed facial expression and in-
creased leucocyte count. Examination reveals
tenderness and muscle rigidity over the site of
inflammation. These signs are all well known
and should need no comment except to emphasize
the necessity of more care in looking for and
recognizing them in time. Justifiable errors are
often made by competent physicians in some cases
of perforating gastric and typhoid ulcers, but by
more care and watchfulness in cases of typhoid
and careful consideration of previous history in
gastric and duodenal ulcers, fewer mistakes
would be made and earlier surgical treatment in-
stituted. The leucocyte count is very important
in diagnosing these cases, a sudden definite in-
crease in the count being a signal for careful in-
vestigation. It is sometimes difficult. to differen-
tiate between some cases of acute infections of
the abdomen, such as appendicitis, and gastro-
enteritis in children, intussusception, typhoid
fever and some diseases of the chest with pain
and rigidity of the abdomen, renal calculus and
others, notably gastric crises. In some cases of
gastric and typhoid ulcers, diagnosis is difficult,
but careful examination and application of well
known principles of diagnosis will usually reveal
the correct condition in most cases. In some
cases exploratory laparotomy becomes advisable
rather than waiting until late symptoms develop.
Little is necessary to be said about treatment
of these cases. Early surgical interference in
every case of acute abdominal infection is of
course necessary. The earlier surgical interfer-
ence is instituted the better. The abdomen should
be carefully opened and in every case where acute
infection is suspected, healthy peritoneal surface
should be carefully walled off from the suspected
area of infection, as the first step of the operation
before the suspected area of infection is dis-
turbed.
This point should hardly need emphasis but it
is too often carelessly disregarded on account of
unnecessary haste and carelessness. If in doubt
as to the presence or absence of pus at the be-
ginning of a laparotomy, the golden rule should
be to assume that there is pus and carefully wall
off healthy tissues before taking the chance of
spreading infective material from a ruptured ab-
scess to healthy peritoneum. Safety first is an
excellent guide in these doubtful cases and will
spell success in many cases if always adhered to.
I consider no other procedure or rule as import-
ant as this in the operation of any infected ab-
dominal case. Another point of importance is to
operate as rapidly as is consistent with careful
surgery, and in extreme cases to do as little as
necessary to save life when in the presence of
shock and an extremely sick patient. Thorough
drainage of abscesses, removal of the focus of in-
fection whenever possible if consistent with safety
to the patient, and proper after treatment are the
general rules of surgical treatment. Quieting of
peristalsis by withholding food, stomach lavage,
protoclysis and hypodermoclysis for elimination
of toxins, rest by administering opiates if neces-
sary, combating shock by conserving blood during
the operation, administration of a minimum
amount of anesthetic, administering drugs such
as pituitrin and camphor in oil in extreme cases,
elevated head position, are points of importance in
after treatment.
In conclusion, I wish to emphasize again, the
VoL. XII, No. 41
Journal of Iowa State Medical Society
145
importance of applying more carefully well
known principles of diagnosis and be alert for
signs of acute infections of the abdomen in every
patient with any suggestive abdominal symptoms,
no matter how young or old, early in the disease ;
considering many of these late cases as prevent-
able by earlier treatment, and the necessity for
careful operative procedure and adequate after
treatment. In short, it seems safe to say that in
cases of acute abdominal infections more than
any other in medicine and surgery, it is more im-
portant to review and always remember many old
points that we already know rather than seek new
ones, and above all make continued effort to
make earlier diagnosis, and institute careful sur-
gical treatment at the earliest possible moment,
always remembering that time, watchfulness and
application of knowledge of well known principles
in diagnosis, and gentleness and thoroughness in
surgical treatment, are cardinal principles, the
more careful application of which will reduce the
mortality in acute infection of the abdomen.
THE SIGNIFICANCE OF SACRO-COCCY-
GEAL DERMOIDS IN RELATION TO
RECTAL DISEASES
A. P. Stoner, M.D., F.A.C.S., Des Moines
A study of the origin of dermoids requires con-
sideration of the errors which take place in the.
anatomic development, beginning with the in-
vertebrates. Life having originated, as is well
known in sea water, we find that the first pro-
cess toward the development of the higher and
more complicated life mechanism, is found in
the primitive straight gut and cephalic stomach.
Then followed the amphibian, with its ability to
live in air, as well as in water media ; in some
instances the swim-bladder being converted into
lungs, and in others respiration taking place
through pores in the skin. Around the primitive
gut was developed the nervous system and brain,
which finally displacing the primitive gut and
cephalic stomach, gave way to the higher de-
veloped vertebrated animal. Dermoids being
only one instance among the multiplicity of er-
rors of anatomic development, it is with exceed-
ing interest that we study the many rare and
curious deformities that may take place, some
being of passing interest only, but many requiring
surgical interference in order to correct a condi-
tion which may hazzard either the health or life
of the individual, many cases however, being ir-
reparable. For instance, one may find anomalies
of the spine and head, due to overproduction of
fluid on the one hand as in hydrocephalous, or a
failure of union of the component parts of the
skull may occur as a result of paucity of fluid,
resulting in anencephalous. In some instances
there is a failure in the closure of the neural
canal from the occiput to the caudal extremity.
Spina-bifida is a defect quite commonly met with
in which the caudal end of the spine is open at
birth, the cause of which lies in the inter-position
of membrane between the bony arches from over-
production of fluid within. The caudal end of
the spine is last to unite, hence the frequency of
this deformity, in that the fluid pressure be-
comes greater as the bony arches close in from
above. The cause of talipes is said to lie in the
caudal extremity of the cord and its appendages.
The neural canal is much longer than the noto-
cord from which is developed the spinal column,
but later on the growth of the latter far exceeds
in length the cord proper, which ends in the
lumbar spine. In the growth of the spine down-
ward and its failure in certain parts to unite, ad-
herent bands may form about the nerve roots ;
occult spina-bifida therefore should be born in
mind as the causative factor in talipes. For the
relief of this deformity Jones^^ and Severs^ have
undertaken to relieve the pressure by dividing
bands and relieving adhesions. Coccygeal der-
moids likewise have their origin in the over-
growth of the caudal spine. The neural canal
originally reached to the integument at its caudal
end, and as the bony parts over-run the neural
mechanism, bits of skin and other ectodermal ele-
ments may be carried inward and lodged in the
vicinity of the coccyx or lower sacrum. The
origin of teratoma, sometimes found within the
coccygeal body may thus be explained. The
coccygeal body is a vestige of the neuro-enteric
canal, and contains elements of the cord and
blood-vessels. The teratomata found here con-
tain elements of nerve tissue from the neural
canal, mucous membrane from the bowel, bone
from the coccyx, and elements from the integu-
ment.
According to Bland Sutton, dermoids may be di-
vided into four groups, namely : Sequestrum der-
moids ; tubulo dermoids ; ovarian dermoids, and
dermoid patches. Sequestrum dermoids are found
along the body midline where in the embryo, the
two ectodermal layers become fused, and cells of
the same being pinched off in the process of fetal
development. Posteriorally, they occur anywhere
along the spine, along the perineum, in the scro-
tum, penis, along the front midline to the neck,
1. Jones, R.; British M. J., 1891, i, 173, quoted by Severs.
2. Severs, J. W. : Spina Bifida Occulta. Boston Med. and
Surg. Jour., 1909, clxi, 388.
146
Journal of Iowa State Medical Society
[April, 1922
face and scalp, orbits and facial fissures. In ex-
tent, dermoids of this class may represent only a
fissure, a fistulous tract lined with surface epi-
thelium, or they may be found as masses contain-
ing hair, sebaceous glands, etc. Tubulo dermoids
are found as remnants of the embryonic canals
which normally become obliterated before birth,
namely, the thyroglossal duct, brachial cysts, the
post natal gut, etc. Ovarian dermoids occur in
the ovary, and may contain any or all of the ele-
ments above enumerated. Aloles are congenital
pigmented patches and not infrequently are the
starting point of malignant growth. Post-sacral
and post-coccygeal dermoids are of frequent oc-
currence, and often arise from the prenatal vest-
ige of Luschka. They may lie dormant during
the life time of the individual, their presence
not being manifested by any symptoms whatso-
ever ; or they may become the seat of neurotic
disorders, and owing to their low degree of vi-
tality, being a sequestration and non-functionat-
ing foreign mass, they are prone to degenerative
changes and are subject to the infections, in
which case they become a distinctive pathological
asset and require treatment. The process may
extend into the adjacent bone, producing necrosis.
One of the interesting forms of sequestration
dermoids is the pilonidal cyst, found in the re-
gion of the coccyx. They often contain bits of
hair, hence the name. The microscope shows the
sac to contain skin elements, debris and pus cell,
the walls being lined with epithelial cells. Pain
and tenderness usually follow infection of the
process, the tension on the walls leading to the
formation of one or more sinuses that open on the
integument in the immediate vicinity. However,
it may burrow downward beneath the fascial lay-
ers for a considerable distance, and open within
the anus, forming the so-called incomplete or
internal blind fistula, or it may open externally
on the ano-perineal region without involvement
of the rectal tissues. Infected dermoids lying in
front of the sacrum may discharge into the rec-
tum, or following the course of least resistance,
open finally near the anal border on the outside.
.4.11 rectal fistulae are the result of abscess forma-
tion, some of which undoubtedly originate from
dermoid cysts in the sacro-coccygeal region. One
has only to point out some of the dismal failures
to cure fistulous tracts of this region, after re-
peated and mutilating operations, to be reminded
that the primary lesion, the real source of the
trouble, had evaded the efforts of the operator.
If the origin is cystic in character, its secreting
walls must be destroyed in order to effect a cure.
In one case, the coccyx was removed in order to
provide room for a thorough curettage of the
walls of what undoubtedly was a cystic process of
fetal origin, situated in front of the sacrum with
a sinus opening externally near the border of the
anus. A cure was thus effected, after two un-
successful attempts by other operators had been
made to cure fistulous tracts about the anus. An*
other case, that of a private soldier in the base
hospital. Ft. Riley, Kansas, with an intractable
fistulous tract, surrounding the posterior and
left borders of the anus. He had been operated
upon for its relief without success. After laying
open the sinus, a search was begun for a com-
munication with a larger cavity. I was lead to
do this because 30 c.c. of permanganate of postas-
sium solution had been injected into the tract for
straining, none of which had entered the rectum.
A minute sinus was found leading up to a large
cavity to the left and posterior to the rectum. A
free communication with the cavity was estab-
lished, and after removing a large amount of
detritus, and thoroughly curetting the walls, it
was treated with gauze packings until healing
was completed at the end of six weeks. The in-
siduous onset, and long standing of this case,
leads me to believe that it was a cystic process of
fetal origin. The following case illustrates be-
yond question the importance of dermoid tissue
as a source of peri-rectal infection.
The patient, a bookkeeper, age thirty-two, experi-
enced sudden pain in the region of the anus, and
thinking his condition due to hemorrhoids, purchased
a “pile remedy” which he inserted into the rectum.
The day following, I was consulted, as the patient
believed that the suppositories he had used had
aggravated his condition. Examination showed the
rectum and immediate anal region to be normal. At
the base of the scrotum, however, about 8 c.m. from
the anterior anal border, and 2 c.m. to the left of the
median line, a phlegmon was found that was dis-
charging pus. The untimely rupture of the abscess
occurring as it did soon after applying the “pile
cure,” led him to the erroneous belief that the irri-
tation and discharge was due to the activity of the
remedy employed. From the abscess a probe was
readily passed through a sinus leading backward to
the anus, the point of which impinged upon the fin-
ger inserted into the rectum, but it did not enter the
lumen of the bowel. Four days afterward, April 12,
1920, he entered Mercy Hospital. Under ether anes-
thesia, the sinus was injected with a solution of
potassium permanganate. It was noted that none of
the solution entered the rectum, which established
the fact that it was entirely extra rectal. The sinus
was then laid open. It hugged the left border of the
external sphincter, thence backward and upward, to
the posterior surface of the coccyx, where it ended
in a mass of necrotic tissue, in which was embedded
two or three fine hairs. The posterior arm of the
sinus next to the anus admitted only the finest probe.
VoL. XII, No. 4]
Journal of Iowa State Medical Society
147
The sac and posterior half of the sinus was com-
pletely dissected out and closed with silk-worm gut;
the remainder being left open, and packed with
gauze. Healing was completed in five weeks.
Without the aid of staining solution, it is often
impossible to follow fistulous tracts, which may
be narrow and tortuous. Moreover, unless one
bears in mind that the source of the infection
may lie in an infected sacro-coccygeal dermoid,
failure to cure will result, if only the superficial
tracts are dealt with.
PHYSICIANS WHO LOCATED IN IOWA
IN THE PERIOD BETWEEN 1850
AND 1860
D. S. Fairchild, M.D., F.A.C.S., Clinton
Dr. Martin H. Calkins
Through the courtesy of Mrs. Mary Calkins
Chassell we have been able to secure important
data relating to the life of her father Dr. M. H.
Calkins who was an early physician in Wyoming,
Jones County, Iowa.
It gives us a deep sense of pleasure to record
the life and work of one of that group of earnest
men who came to Iowa in the early days of its
history and helped to lay a solid foundation upon
which to build a commonwealth. It is also equally
a pleasure to point out the facts in relation to Dr.
Calkins as an exponent of the highest ideals as a
practitioner of medicine. We have already writ-
ten of a group of physicians who did not count
financial gains as the great purpose in life but
only incidental and subordinate to service and
duty. These men were strong men who gave their
lives to the public, reserving only the wages of
honest service to humanity and state. To com-
mercialize their profession was abhorrent, to
measure service by money standard was intoler-
ant; they were men, true men from whom we
should gain inspiration. It is not too late.
Dr. Martin H. Calkins was born near the town
of Mexico, Oswego County, New York, Septem-
ber 15, 1828. He was of Mayflower and colonial
ancestry on both the maternal and paternal sides.
He was educated in the common schools and at
the age of seventeen began teaching in the coun-
try schools and later in the City of Oswego. He
was teaching in that city when the first train of
cars arrived. He held a teachers state certificate
which was number six in New York State.
After reading medicine in the office of Doctors
Bowen and Dayton in Mexico, he took a course
in the College of Medicine in Geneva, New York,
completing his medical studies in the University
of New York City.
He commenced practicing in Constantia. He
was married November 8, 1855 to Miss Lucinda
Louden of North Bay, Oneida County, New
York.
On the 14th of June, 1856, he came to the new
State of Iowa and after spending a few weeks in
DR. M. H. CALKINS
Maquoketa came to Wyoming in Jones county
which was then a town of a dozen houses, but
hopeful and growing rapidly. The surrounding
country was a most beautiful rolling prairie, rap-
idly being peopled by settlers who were busily en-
gaged in breaking the virgin soil and laying the
foundations for the beautiful homes and farms
of Jones county.
The young Doctor built a dwelling on a block
cornering on Main and Y'ashington streets. It
was modest in size and the lumber was black
walnut. Here on these same lots but in a more
pretentious house built in later years, Dr. Calkins
resided and practiced his profession for nearly
fifty years. As a physician he was eminently suc-
cessful, and held his ver}" large practice perhaps
as much by his social, genial strength of character
and magnetic influence and the sunshine that al-
ways entered the sick room with his presence, as
by the administration of drugs.
His personality was a force for good not only
in the sick room but in the entire growing com-
munity, and he was looked up to as a safe adviser
and counselor. During his long practice, he re-
COME HELP TO MAKE THE ATTENDANCE 1000
□
iititimiiitii
iiMimmiimiitiii
immiiiiiiMiimii
□
DeS MOINES extends a most
hearty welcome to the Medi-
cal Profession of the State to
be her guests at another An-
nual Session of the Iowa State
Medical Society.
Your presence will add to the
success of the session, both
professionally and socially.
Come —
Bring your family and friends.
Help to make the attendance
one thousand or more, and
enjoy the program that has
been prepared for you.
imumiuiimiuimuiiimi
ORGANIZED 1850
Seventy-first Annual Session
May 10, 11, 12, 1922
Official Program and Announcements
Page 125
ARRANGEMENT COMMITTEE
Dr. Alanson M. Pond . . Dubuque
Dr. Tom B. Throckmorton . Des Moines
Dr. Thos. F. Duhigg . . Des Moines
Dr. VV. E. Sanders . . . Des Moines
Dr. \V. J. Fenton . . . Des Moines
I
Des Moines Civic Center |
♦ ♦ ♦
Co/isewn, Library, Postoffice, Municipal Building
Municipal Coui't
I Heart of the Business District of Des Moines I
iTiHiiiitHniiMiiiiMtiiniiiiMiiiiMMiiMniMiiiiniiiiiiiiiiitiiintiiMHiiiMniiiitiiMiiiiiiiiMtiiiMiKiiniiMinMMiiiiiiiiiniiMiMiiiiiiniitiinMMiiMiiiiNiitKiniiitinnutiniiniitiiiiniiiiiiiMiiniitMiiniMmniiiiiiiiMiniiiuiiniiiiiiiiiitiiiiiiitiiiiiiiMiniiMinMitiiniMiiiniiiiHiiitiMMiiMnniiiiiHMiinniitinMin
150
Journal of Iowa State IMedical Society
[April, 1922
sponded faithfully and cheerfully to all calls and
we have no knowledge of his ever pressing his
patients for bills, or invoking the courts for as-
sistance in collecting fees from those who should
pay, but did not. It was often said of him that
he never oppressed the poor, or failed in fully
performing every obligation imposed upon a med-
ical practitioner, and because of these character-
istics be held the love and respect of the people.
In 1862 acting as a mustering officer, he ad-
ministered the oath of allegiance and mustered
into the state militia, a company of eighty-nine
men who afterwards formed Co. K, 24th Iowa
Infantry and served their country during the Civil
War. Dr. Calkins erected a monument to these
men and on it their names are inscribed. He
also acted as one of the state commissioners in
the year 1862-3 to go to the Southland and take
the vote of the soldiers then in the field.
Dr. Calkins had but little of the politician in
him and never sought office. But when the town
of Wyoming was incorporated, he was unani-
mously chosen mayor. In 1881 he was nominated
as the Republican candidate to represent the
county in the lower house of the state legislature.
The Democrats making no nomination the Doctor
was unanimously elected. Two years later he
was re-elected, and although opposed by a leading
democrat, polled in A\'yoming township 200 out
of 211 votes cast. In the legislature, he was true
to his party and to his conscience. He was one
of its fifty-two members who voted for the pro-
hibitory law. He led the house in the matter of
oil inspection law and had opposed to him one of
the most active and unscrupulous lobbies who
went so far as to hide the bill after it was re-
turned from the senate. But Dr. Calkins called a
halt during the last hours of the a^embly, had the
bill searched for, found and put upon its passage,
and passed much to the surprise of the lobby who
thought the matter disposed of for that session.
The revenue from this bill to the State of Iowa
amounts to $10,000 or $12,000 to say nothing of
the safety which it guarantees.
Dr. Calkins was a writer of unusual ability and
every day for many years wrote upon some sub-
ject, either scientific, historical or literary as a
personal study. In these moments he forgot not
the town and vicinity of his adoption, but gath-
ered together in chronological order the rem-
iniscences of the early days of the settlement of
Wyoming town and township, weaving a most in-
teresting history that formed a course of lectures
delivered by him to his towns people about 1878.
So fully had the Doctor covered the ground, that,
in 1878, (and in a later histor}^) this history of
Dr. Calkins was incorporated into the volumes.
the editors saying the ground had been fully cov-
ered by the Doctor, and, in language and thought,
was superior to anything the editor could hope to
place in the volumes.
It was a high compliment to the hard working
physician who had thus kept the annals of his
town and vicinity in its early days, and made for
Dr. Calkins a monument as the pioneer historian
of Wyoming, that will live when the marble col-
umn is in dust.
He was a modest man, living the life of one
devoted to his profession, and while his name may
not be found on the church rolls, he followed
closely the golden rule of the Master in his daily
life as an obligation due — one to the other —
among all people. His upright life, courteous
manner and kindly daily life set a standard of
good living to generations of young people in the
community, that has been for the betterment of
the social life of Wyoming and Jones county.
He was out-spoken and fearless in support of
moral reforms and with both pen and voice de-
clared his position on questions of good govern-
ment. As a man. Dr. Calkins was gifted with a
large and comprehensive mental endowment and
scholarly culture. He was large of physical
frame and larger of mind and heart, honest, up-
right in his dealings with his fellow men ; cheer-
ful, warm and open hearted, approachable and
companionable, performing his duty diligently
with contentment and resolution. He possessed
a vigorous personality. His unfailing kindness
and generous impulses, his devotion to his profes-
sion, his proverbial and spicy good humor and
genial disposition, his kindly ministrations to the
needy and those in distress of mind, coupled with
his sound judgment, wide experience and inde-
pendence of thought and action made Dr. Calkins
beloved as a man and citizen to a degree seldom
realized by human experience.
For many years, he served on the board of pen-
sion examiners in Jones county and as local sur-
geon for the C. M. & St. P. R. R.
His practice and the superintendency of his
farms made his life one of constant activity. At
the time of his death he owned a farm in New
York State which had been in the family for one
hundred and twenty-seven years.
Dr. Calkins died September 27, 1909. ]\Irs.
Calkins died December 25, 1915. They are sur-
vived by two daughters : Elva Calkins Briggs
(Mrs. W. E.) Minneapolis, ^Minnesota. Alary
Calkins Chassell (Airs. E. D.) Wyoming, Iowa.
Two grandsons, AJartin Calkins Briggs, a busi-
ness man of Alinneapolis ; Walter Charles Briggs,
a student in Yale. One grand-daughter. Alar}'
Calkins Briggs, a student in high school.
VoL. XII, No. 4]
Journal of Iowa State Medical Society
151
tllje Journal of tfje
3otoa ^tate jHelittal ^ocieti*
D. S. Fairchild, Editor Clinton, Iowa
Publication Committee
D. S. Fairchild Clinton, Iowa
W. L. Bierring Des Moines, Iowa
C. P. Howard Iowa City, Iowa
Trustees
J. W. CoKENOWER Des Moines, Iowa
T. E. Powers Clarinda, Iowa
\V. B. Small Waterloo, Iowa
SUBSCRIPTION $2.75 PER YEAR
Books for review and society notes, to Dr. D. S.
Fairchild, Clinton. All applications and contracts
for advertising to Dr. T. B. Throckmorton, Des
Moines.
Office of Publication, Des Moines, Iowa
Vol. XII April 15, 1922 No. 4
IOWA STATE MEDICAL SOCIETY
The Seventy-First Annual Session of the Iowa
.State iMeciical Society will be held May 10, 11, 12,
1922, at Des IMoines.
Se^•enty-two years ago twenty-five Iowa physi-
cians met at the court house in Burlington to or-
ganize a state medical society for the advance-
ment of medicine. These were big men who came
to Burlington, by steamboat, by stage coach and
on horseback for the serious business of organiz-
ing a medical society of state wide jurisdiction.
No local society had been organized then, there-
fore, in Iowa, medical organization began at the
top. The first local society was in Keokuk
(1850); first county society, Polk (1851). It
was recognized that the state society should be
the center of medical activities, economic, social,
scientific and professional. The organization was
based on political lines of independent state sov-
ereignty, admitting nominal alliance to the Amer-
ican Medical Association.
There were no laws governing the practice of
medicine, each was an individual practitioner
amenable to the code of a gentleman. When the
state society was organized, the written code of
the American IMedical Association was adopted
and this was the beginning of an “Autocracy in
Medicine” as we hear from time to time.
Following the close of the American Revolu-
tion, the thirteen colonies about to become states,
feared the adoption of the constitution as endan-
gering their liberties and if the appointment of
John Marshall as chief justice could have been
forseen it is doubtful if the constitution could
have received a sufficient number of votes, and
the several new states would have remained sep-
arate jurisdictions, with what results we need not
speculate. It was not until after the Civil War
that the federal system was apparently securely
established; we say apparently for not once only,
but several times thoughtful men had been appre-
hensive. We often hear of the “American Idea,”
“True Americanism” or similar cries, the mean-
ing of which we do not know and no one attempts
to define. What would have happened if there
had not been a John Marshall to interpret the
constitution or statesmen like Alexander Hamil-
ton and John Adams to lay the foundation of
government, likewise furnish grounds for spec-
ulation. ^
Recently we read an address by a high govern-
ment official before an Association of Life In-
surance Presidents that a great danger came to
this Government when the House of Representa-
tives did away with the rule of Tom Reed and
Joe Cannon in refusing recognition of members
who introduced bills objectionable to certain
leaders. No doubt Mr. Weeks is right, but how
unAmerican the danger of autocracy. Then and
now the cry was raised of danger to American
institutions. Mr. Wilson negotiated treaties and
a League of Nations under strict constitutional
provisions without consulting an unfriendly Sen-
ate; again a danger to American institutions. Mr.
Harding proposed a similar procedure with the
same fears except that his own party is in power.
The Binet Test shows that 12 per cent only of
our people are capable of leadership and we had
fondly hoped that this per cent was made up
largely of the medical profession, but we have
heard ever since the reorganization of the medical
profession, that we were in great danger of a
medical autocracy, the greater the success of the
organization the greater the danger. The same is
true of the American College of Surgeons and the
Standardization of Hospitals. The “American
Idea” has been in danger for nearly 150 years,
and yet we survive. We wonder sometimes why
the danger-mongers do not become discouraged.
In Iowa we are delighted to say these people do
not flourish in the medical profession to any great
degree. We admit that the “great men” in the
profession do not live in Iowa. We do not often
see the names of Iowa physicians on national
committees, neither do we see or hear of Iowa
physicians identified with measures to defend the
“American Idea” — whatever that may be — but we
152
Journal of Iowa State Medical Society
[April, 1922
do see 25CX) medical men earnestly endeavoring to
make conditions better. M e do not see our pages
filled with warning of university autocracy, of
the dangers of state medicine, of the dangers of
maternity bills or other awful things.
We realize with other interests that conditions
are changing. The old men are sometimes dis-
tressed because the practice of medicine is not as
it was in earlier days ; the men of middle age are
disturbed by the strenuous competition ; that the
young men disregad the traditions of the past, and
look upon the field as their own; and that the
business and professional methods of the past are
obsolete. Then differences in viewpoint have led
to divisions in hospital relations and combina-
tions, and medical society discord, but we have
seen all this before, although now somewhat ag-
gravated by the greatly increased cost in medical
education, and increased cost' in conducting a
medical practice. These conditions are reflected
upon the general public, who find or think they
find lower standard of medical ethics, greed for
money and more commercialism. The general
public think that while there is a greater technical
knowledge among physicians, there is a less broad
literary- culture, and that doctors’ libraries do not
compare favorably in books, and high grade mag-
azines, with other educated classes.
The cure for these criticisms lies in the hands
of the physicians themselves. The personal rela-
tions of physicians will work themselves out by
a process of evolution. The social side, which is
of great importance in the eyes of the public, can
be greatly improved by local and state medical so-
ciety— attendance. We observe a decided im-
provement in this direction, particularly in the
smaller cities where the county society meeting
is an event of social importance which particu-
larly attracts the attention of the public. The
state meeting is also an event. We ought to see
1,000 members present with members of their
families as far as possible. We feel that we can
assure the profession a greatly improved public
status if instead of 500 we have 1,000. The
sacrifice will be more than compensated from
the viewpoint of the public, and instead of com-
plaining because the public overlooks us we com-
pel the attention of the public by filling all the
spare space, other conventions do this and so can
we do the same.
In the February, 1919 number of the Edinburgh
Journal, Robert Knox, M.D., urges the importance
of a place of radiology in the medical curriculum and
the need for coordination in teaching.
BRITISH MEDICAL ASSOCIATION
The British Medical Association is established
for the promotion of the medical and allied
sciences and the maintenance of the honour and
interests of the medical profession. It has divi-
sions throughout the British Empire. There are
43 branches, with 215 divisions, in the United
Kingdom, and 44 branches, with 58 divisions, in
the British Empire Overseas.
Any medical practitioner registered in the
United Kingdom under the medical acts, any
medical practitioner who does not reside within
the area of any branch of the association and who
though not so registered is possessed of any of
the qualifications described in Schedule (A) of
the Aledical Act, 1858, and any medical practi-
tioner residing within the area of any branch of
the association .situate in any part of the British
Empire other than the United Kingdom who is
so registered or possesses such medical qualifica-
tion as shall (subject to the by-law’s) be pre-
scribed by the rules of the said branch, is eligible
to become a member of the association. Mem-
bers of the association are, ipso facto, members
of the division and branch in the areas of which
they reside.
The liability of members is limited.
The annual subscription, which is due in ad-
vance on January 1 in each year, and entitles the
member to all the ordinary privileges of member-
ship of the association, including membership of
the division and branch in which he or she re-
sides, and the weekly supply of the British Medi-
cal Journal post free, is as follows : Member
resident in United Kingdom, $15.00. (In the
case of newly qualified practitioners elected
within two years of registration, IJ^ guineas
yearly, up to end of fourth year after registra-
tion.)
Member resident in a Branch outside United
Kingdom $10.00 or more according to the Rules
of the various Branches.
Member resident outside Elnited Kingdom
where no Branch is organized $10.00.
Present membership, 23,666.
EARLY BRITISH MEDICAL JOURNALS
The first English IMedical Journal was pub-
lished at George in Fleet-Street, London, June
17, 1684, and contained fifty-six pages under the
title of IMedicien Curiosa. The second and last
number October 23, 1684, contained sixty-four
pages. A number of short lived journals ap-
peared at various dates from 1757 onward.
VoL. XII, No. 4]
Journal of Iowa State Medical Society
153
The first real Engli*;h Medical Journal was
founded by Dr. Simmons in 1781 called “The
London Medical Journal;” ten years later its
name was changed to Medical Facts and Obser-
vations; it ceased to appear in 1791. The Medi-
cal and Physical Journal was founded in March,
1799 by Dr. T. Bradley and Dr. F. M. Willich
and continued until 1833. The Lancet was
started by Dr. Thomas Wakley in October, 1823
and was the pioneer medical journal among those
still existing; the British Medical Journal first
appeared in 1840 under the name of Provincial
Medical Journal. It soon changed its name to the
Provincial Aledical and Surgical Journal as the
organ of the Provincial Medical and Surgical
Association founded by Sir Charles Hastings in
1832. But in 1856 when the name of this associa-
tion was changed to the British Medical Associa-
tion the name of the Journal was also changed to
the British Medical Journal.
CANADIAN MEDICAL ASSOCIATION
At the recent meeting of the Canadian Medical
Association at Halifax, a resolution was adopted
increasing the annual fee for membership includ-
ing the Journal to $10.00 beginning January, 1922.
It is believed that with the increased income,
greater service may be rendered its members, and
the Journal improved. This important fact is be-
ing realized by medical organizations in general
and there is growing tendency to increase dues
to meet the increased activities that fall upon the
societies in their relations to the public.
ASSOCIATION OF JAPANESE MEDICAL MEN
Japanese medical men in Berlin, to the number of
forty, have formed an association, one of the pur-
poses of which is to re-establish relations between
German and Japanese medical men, which were
broken off by the war. With this purpose in view,
the association organized last month a special ses-
sion, to which the directors of all the institutes in
which Japanese physicians are engaged at the pres-
ent time were invited. The invitation included the
dean of the medical faculty (Geheimrat Rubner), the
presidents of the medical societies and certain repre-
sentatives of the medical press. Following the
special session, a banquet was held, at which several
Japanese gave expression to their gratitude for the
part that the Germans had played in the advance-
ment of Japanese medicine. The announcement that
the owner of two widely read Japanese newspapers
had contributed 300,000 marks for the relief of Ger-
man children made a very favorable impression. —
Tour. A. M. A.
IOWA STATE UNIVERSITY NEWS NOTES
Don M. Griswold, AI.D.
“Dad’s Day” was celebrated at the University in a
very fitting manner. Fathers of the students in all
colleges were invited to come to Iowa City on Feb-
ruary 25, and get acquainted with the faculty mem-
bers and the environment of their sons and daugh-
ters. IMany of the physicians of the state who had
sons or daughters took occasion to come to Iowa
City at this time to bring patients to the hospital ot-
to visit the clinics.
Helen Stewart, director of the school of public
health nursing, was in Sioux City February 13 to
give addresses on “The purpose of the school of pub-
lic health nursing,” to the nurses of Samaritan Hos-
pital, Visiting Nurses’ Association, and the Public
Welfare Bureau.
The Johnson County Public Health Association
met at the city hall, March 4, in Iowa City to outline
a constructive health program for Johnson county.
Notice has been received from the war department
that all students in the Univ'ersity who are taking the
advanced course in the R. O. T. C. will receive six
weeks of field training at Carlysle, Pennsylvania, this
summer. The work of the Reserve Officers Train-
ing Corps during the school year is entirely theoret-
ical and given in the class rooms, so that it is highly
desirable to give the students practical training under
field conditions before granting them their commis-
sions in the Reserve Corps.
Dr. L. W. Dean attended a meeting of the Iowa,
Nebraska, and South Dakota Clinical Congress at
Lincoln, Nebraska, February 6. This Clinical Con-
gress is the Tri-State Section of the American Col-
lege of Surgeons. Dr. Dean is a member of the
Credentials Committee and reports that a number of
very able surgeons of this district were enrolled in
the organization.
The department of hygiene and preventive medi-
cine, medical college is in receipt of a fresh supply of
polyvalent Botulinus antitoxin. Physicians who have
reason to believe that they are dealing with a case of
Botulinus poisoning may have this material free of
charge on telephonic request.
Considerable interest was manifested recently in a
sophomore medical student who was found to be an
excellent case of situs transversus. The classes in
physical diagnosis have enjoyed greatly the novelty
of examining such a case.
The laboratories for the State Board of Health
called attention to the fact that of the unusually
large number of heads sent to the laboratory for ex-
amination for rabies, a considerable number have
Secure Your Hotel Reservations at Once — For Hotels, See Advertising Pages iv, vi, and viii
154
Journal of Iowa State Medical Society
[April, 1922
been found positive. Among the heads sent in for
examination have been — one weasel, one tame black
squirrel, one horse, and seven cows.
It is recommended that physicians be on the look-
out for rabies in domestic animals.
The Annual Clinic of the College of Medicine will
be held ^londay and Tuesdaj-, April 11 and 12. This
is an annual event which has proven very popular
and brings several hundred members of the profes-
sion from all parts of the country to see the work in
the clinics here. The program for this year is un-
usually attractive and can be had by request to the
junior dean.
Dr. Paul R. Rockwood and Dr. J. B. Synhorst have
received fellowships to the department of internal
medicine of the Mayo Clinic. These men graduated
with the class of 1921 and are just completing their
internship in the department of clinical medicine at
the University Hospital. The fellowship was granted
by the Maj’O Foundation and carries a liberal stipend
for three years.
On February 10, Dr. L. W. Dean presented a pa-
per before the Otological Section of the New York
Academy of Medicine, on the “Tonal Ranges in Le-
sions of the Acoustic Nerve, and its end Organ.”
Four representatives of the University presented
papers before the meeting of the American Associa-
tion of Medical Colleges in Chicago, March 6 to 10.
The men who represented the State University of
Iowa at this meeting are. President W. A. Jessup,
dean, L. W. Dean, Dr. T. T. McClintock, and Dr. Don
M. Griswold.
Dr. Lawson G. Lowery, assistant director of the
Psychopathic Hospital made a report on March 7 of
the psychiatric survey of the children at the juvenile
home, Toledo, Iowa.
Drs. Byfield, Davis, Tones and Griswold have just
completed a survey of the State College for the Blind
at Vinton. The special lines investigated by each of
these men were nutrition, eye, ear, nose and throat,
general medical conditions and sanitary matters. The
report will shortly be filed with the state board of
education.
A temporary building has been constructed east of
the University' Hospital to be used as a venereal dis-
ease hospital. This building will have forty beds and
be thoroughly equipped for handling this number of
hospital cases. The purpose of the new' hospital is to
co-operate with the U. S. Public Health Service and
the State Board of Health in their effort to suppress
venereal disease and to increase the facilities avail-
able here for this phase of the w'ork. Patients are to
be admitted on the same basis as to other wards of
the U^niversity Hospital, and it is anticipated that
many cases will be received under the Perkins-Has-
kell clause laws. Dr. N. G. Alcock, professor genito-
urinary diseases, w'ill be in charge with an augmented
staff.
THE HOSPITAL SURVEY OF THE COLLEGE
IN 1921
In January of this year, when the hospital program
of the college for 1921 was evolved, it was decided
to limit the survey to thirty months of hospital visit-
ing. This was from necessity rather than from
choice. Consequently, hospitals which w'ere fully ap-
proved in 1920 were not revisited this year. Follow-
up visits to these hospitals, however, were postponed
only temporarily. Particular attention was directed
toward those hospitals w'hich either were not on the
approved list last year or which w'ere listed w'ith an
asterisk. In addition, as many as possible of the
fifty-bed hospitals were visited also.
The survey was conducted through personal visits
by a corps of seven hospital surveyors. These men —
all physicians — were from medical schools and hospi-
tals of widely separated sections of the country.
They were given a course of training at the college
headquarters, follow'ed by survey work with experi-
enced hospital visitors. This uniformity in training
assured the college of uniform reports, which consti-
tutes one of the essential features of the college pro-
gram. Whether a hospital were in Maine, therefore,
or in California, each institution was visited and sur-
veyed on the same basis. Further, by visiting a large
number of hospitals scattered over a wide range of
territory, these surveyors obtained a general, rather
than a local viewpoint. This policy of personal visits
by relatively few, uniformly trained hospital survey-
ors in one of the most important elements of the
college program.
There are certain difficulties experienced by hos-
pitals in their endeavor to meet the standard of the
college which merit special emphasis.
Relative to staff organization, one of the chief dif-
ficulties seems to be the adoption of a type of staff
meeting which actually analyzes the clinical results.
Slowness in developing a co-operative, group spirit
among the physicians seems to be the chief hin-
drance. As this spirit develops, the purpose of the
staff meeting becomes more nearly realized. In the
average hospital a combined staff meeting is essen-
tial. Teaching hospitals, however, and other hospi-
tals with highly specialized staffs, and hospitals hav-
ing a staff membership of only one or two physi-
cians, form certain exceptions to this rule. In such
instances, departmental conferences, teaching clinics,
and individual analyses take the place of the com-
bined staff meeting.
The adoption of an official resolution prohibiting
fee-division has been a second stumbling block in
many hospitals. Hospitals which have been slow to
respond may be divided into two groups. In the
first group are institutions, in which, apparently, the
practice has not been unknown and where, conse-
quently, difficulty was expected. It was a distinct
VoL. XII, No. 41
155
Journal of Iowa State Medical Society
surprise, however, to meet opposition to passing such
a resolution in some hospitals of the second group,
having a high ethical status in communities or sec-
tions of the country where the practice of fee-divi-
sion is practically unknown. Some of these hospitals
were very hesitant about passing resolutions con-
demning the practice. When thej- began to realize,
however, that they served as powerful examples for
other hospitals in which the practice was prevalent
and that the college must apply a uniform policy to-
ward all hospitals, they responded. That the view-
point and stand of the college in this matter is amply
warranted is evidenced by the impression gained by
our hospital visitors, that the practice of fee-division
is present to some extent in nearly every state and
province, even though it may be practically unknown
in some sections.
Case records are improving steadily although they
still constitute the greatest difficulty in many hospi-
tals. Two factors stand out most prominently in
impeding the development of proper case-record sys-
tems in hospitals: first, the lack of proper interest in
the case records by physicians and hospital execu-
tives themselves; second, the lack of internes. The
first is just as important as the second, because even
a full quota of internes without sufficient supervision
will often fail to secure adequate records. When
the hospitals do their share in supplying sufficient
record facilities and personnel, and the staff mem-
bers co-operate by exhibiting proper interest in su-
pervising the records, most of the difficulties in this
connection will be solved.
Laboratories have shown a similar steady improve-
' ment. There is a demand for laboratory equipment,
technicians, and pathologists, which has been hitherto
unknown. One handicap to the development of ade-
quate laboratory service is the system of making a
separate charge for each laboratory test performed.
This difficulty has been obviated in many hospitals
by establishing a flat-rate fee to include most of the
usual laboratory tests. Tissue examinations should
be included in this flat rate, otherwise it is difficult
to obtain routine examination of all tissue removed
at operation. Although the flat-rate fee may not be
applicable in all hospitals and may be inadvisable in
some, it has been of tremendous help to many hos-
pitals in solving their laboratory problems.
Last year, out of the 704 hospitals in the United
States and Canada having a capacity of more than
one hundred beds, 407, or 57 per cent, were on the
approved list. Of that number 193, or almost half,
were listed with an asterisk.
This year, the total number of one-hundred-bed
hospitals has grown to 761. Of this number 568, or
74 per cent, are on the list. Of these 568, 18 per
cent, are listed with an asterisk, showing the great
relative decrease in the number of hospitals listed
with an asterisk this year. The asterisk has been
used to indicate those institutions which, although
they have instituted measures adopting the funda-
mental principles of the standard, have not developed
them to their fullest efficiency at the present time.
Besides these larger hospitals, 704 of the fifty-bed
hospitals were visited during the past two years.
According to our records, there are about 875 of
these hospitals, leaving about 150 which have not
been visited. It is the hope of the college to visit
all of these smaller hospitals next year, so that they
may be included in the next approved list. The total
number of hospitals visited by our hospital survey-
ors this year is 1,007.
The attaining of the minimum standard, of course,
is not purported to be a resting place in the pathway
of a hospital’s progress. It is no ultimate standard.
There are many things beyond. It does, however,
contain the basic fundamentals and that, doubtless, is
why so many hospitals have adopted it. — Frederick
W. Slobe, M.D., Chicago, Hospital Standardization
Department, American College of Surgeons.
THE STANDARDIZATION PROGRAM OF THE
AMERICAN COLLEGE OF SURGEONS
This is the first time I have been put down on the
program to present the plan of the American College
of Surgeons. And yet I think, during the three and
a half or four years that I have been co-operating
with the college, I have always been talking on that
topic.
You have heard already what are the requirements
of the standard. You have heard a great deal about
organization of the staff, about the records, about the
laboratories, and the division of fees, and about the
autopsy work. I shall not go into any technical de-
tails because they have been set before you by those
who have technical knowledge. I shall try to pre-
sent to you, in as few words as possible, what seem
to me to be the great historic facts of this movement
for better hospitals — the scientific fact that underlies
it, the ethical basis of it, and its bearing on the re-
ligious thought and feeling and spirit which is in-
evitable.
Historically, the Council on Medical Foundation
began this movement for better hospitals when it
began to make the medical schools better and when,
following that wonderful movement, it began to look
to the interests of the interne some eight years ago.
Some five or six years ago, the American College of
Surgeons, stirred down into the depths of its soul,
began to realize that it had a mission for the better
care of the sick in the L^nited States and Canada and
made up its mind, as you all know and have been
told, to improve surgery. But everybody also knows
that you cannot improve surgery unless you improve
everything that centers in the work of the hospital.
And so the American College of Surgeons had not
gone very far with its efforts and purpose to improve
surgery when it realized that it had to improve ev-
erything in medicine.
Knowing that the Council on Medical Education
had begun this work, the college, in its fine spirit of
honor and regard for the profession, went and said:
“This is what we want to do; what are you going to
156
Journal of Iowa State Medical Society
[April, 1922
do?” And the reply was: “Go on and do your work
and we will stand by and help you.” Therefore, you
members of the American College of Surgeons, take
it down deep into your hearts that you have been
doing a wonderful work for the whole profession in
bettering hospital service to the public.
This is the historic fact — absolutely unquestion-
able because I know it from personal experience in
the movement from the very beginning, and hence I
always take an occasion like this to say: “All honor
to the American College of Surgeons.” And further-
more, they are in the middle of the work. It is well
begun. They have gone on, let us say, toward the
middle of it and they must carry it on to the end, be-
cause they are the body of people as far as I can-
judge, capable of finishing the movement, at least up
to that point where it is sure and safe and sound and
destined to go on. That is the historic point of view.
Scientifically, it seems to me that this should be
said: The mind of the medical profession is being
reached as it was never reached before, to make it
more keen, more analytical, more cautious, and more
co-operative in its scientific combination of thought,
in its analysis of assembled facts, in its careful, grad-
ual, step-by-step arrival at a diagnosis. And this
grows out of the organized staff. This grows out of
the monthly staff meeting, or weekly departmental
meeting, as the case may be. It has brought about
that the medical profession working in the hospital
has come to the conclusion that minds must get to-
gether, that facts must be assembled, and the right
analysis of those facts arrived at either by the indi-
vidual, a small group, or the whole staff. In other
words, gentlemen, without intending ,t, as I ob-
served throughout the continent, the medical mind
is being convinced by this program of yours that
the time for independent and separate and distinct
and hostile personal thinking is past in medicine.
Today everybody is convinced that no medical
thought is finally safe for the patient, for the public,
until several minds have agreed. Standardization,
therefore, in as far as it means organization of staff,
in as far as it means monthly conferences, has meant
a great development of the medical mind throughout
the country, and, above all, a great development of
medical character. Men today, instead of being dis-
tinct individuals, are growing into the greater stature
of men working with their fellows, an embodiment
of much greater capacity and character communi-
cated into action.
Just one more word about these monthly confer-
ences. I believe there is an incomplete appreciation
of what they mean. The college speaks of them as
clinical conferences, as investigating the clinical expe-
riences of the hospital. But the college does not say,
except impliedly, that in these monthly conferences
lies the secret of the success of the whole movement.
Your records will not amount in value to the paper
they are written on, your laboratories will be useless,
you will get no autopsies worth while, the unjust di-
vision of fees will go, unless your monthly confer-
ences are genuinely, are sincerely, are absolutely
high-minded and get down into the very heart and
soul of everj- man. Because, gentlemen, what is the
monthly conference? It is a review of what was
done at the whole institution for every patient that
came into the hospital. I do not care how many sta-
tistics you have, how correct they are, the facts in
figures are without the scientific soul of the facts,
unless the soul of the medical man is big enough to
analyze those facts. Thirteen deaths in the past
month means nothing. Why did each one die? So
many unimproved in the hospital means nothing.
WTy are they unimproved? What has been the use
of the laboratory? Why haven’t we had more au-
topsies? Gentlemen, it is hard, it just tears the soul
out of a medical man to have to face his own failures,
his own incomplete work, his own missing of diag-
nosis, his own failure to have consultation when he
should have had it, his own incapacity to assemble
the great facts involved in the case and then miss in
his diagnosis or fail in his operation or somewhere
in his treatment. They call it a minimum. I call it a
fundamental.
And here let me make a plea, such as was made
here on the stand this morning, for the young man,
for the man that wants to grow. Let the older men
play the big brother. Let them be the outstanding
leaders, not so much in what they know or in their
skill but in their greatness of character, in their readi-
ness to say, “I don’t know, I failed, help me.”
Now, just one more word on that question of the
monthly meeting. The American College of Sur-
geons has a mission. There is an apostleship for
them to take. They have not been brave enough.
They have not been aggressive enough. They have
not in all cases set the great example of genuineness
in these monthly meetings. Those monthly meetings
cannot be like the county medical meetings or those
of any special association and at the same time at-
tend to the business of the monthly meeting. What
has been done for our patients? Where have we
failed? Where have we succeeded? Papers, discus-
sions, cases are not the real thing in those meetings.
There is no intention on the part of the college to
displace county medical meetings, to displace the
work of your specialist society, which is all one
thing. What has this hospital, from top to bottom,
from engineer to superintendent, including the
nurses, the orderlies, and everybody — what have we
done for our patients during the past week or
month?
The college started with the thought of bettering
surgery. They are in the midst of bettering the
whole practice of medicine. Why? Because the
heart of the movement, the heart of the record, the
heart of the monthly meeting, the heart of the ser-
vice in the laboratory — I mean scientific heart and
ethical heart — is diagnosis. It all centers on diagno-
sis; no hurried, no snap-shot, yet no elaborate (be-
yond human frailty) diagnosis, but a genuine, sin-
cere, a definite, direct, cautiously and deliberately ar-
rived at diagnosis of what is the matter with the pa-
tient. That is the heart and soul of medicine.
VoL. XII, No. 4]
Journal of Iowa State Medical Society
157
Here again I would like to say a word of coiii-
niendation, a word of praise, a word of congratula-
tion to the members of the American College of Sur-
geons throughout the country for the thoughtful, the
really scientific, and the deeply conscientious way in
which they are going at this program. There is no
doubt about it, gentlemen, if I am at all safe in my
conclusion on the reading of medical history, that
there has never occurred a movement equal to it in
the past history of our race. Here we have a great
body of men on a great continent — and it is sure to
reach the rest of the world — facing a tremendous
ethical responsibility by a keen administration that is
scientific of the laws of health. It is done because
you all, down deep in your hearts — and particularly
is it true of the hearts and minds of those men who
have led the movement. Dr. Franklin Martin, Dr.
John Bowman, and others in the office who have led
the movement — feel that it is the greatest in the his-
tory of medicine.
If I may be allowed just a few more words: At
the first meeting you had in Chicago, when you be-
gan this plan, I was fortunate enough to be asked
to address you. There were there three hundred
members of the American College of Surgeons and
the title of the program was “Hospital Standardiza-
tion.’’ And I can recall with a great deal of vividness
that at the end of the morning program I arose and
I said: “Gentlemen of the American College of Sur-
geons, your title may be all right but I am going to
be bold enough to say to you that it means not
primarily standardization of hospitals but it means
the standardization of the medical profession, in
mind, in character, and in heart.’’ — Rev. Charles B.
Moulinier, S. J., Milwaukee, President, Catholic Hos-
pital Association.
DIVISION OF FEES
An article in the Amended Constitution of the
Kentucky State Medical Society on membership
reads as follows:
Section 1. All members of the Component County
.Societies shall be privileged to attend all meetings
and take part in all the proceedings of the annual
session, and shall be eligible to any office within the
gift of the association. Provided, that no physician
may become a member of any county society unless
he signs and keeps inviolate the following pledge.
“I hereby promise upon my honor as a gentleman
that I will not so long as I am a member of the
Kentucky State Medical Association practice divi-
sion fees in any form; neither by collecting fees from
others referring patients to me nor by permitting
them to collect my fees for me; nor will I make joint
fees with physicians or surgeons referring patients
to me for operation or consultation; neither will I
in any way, directly or indirectly, compensate anyone
referring patients to me nor will I utilize any man as
an assistant as a subterfuge for this purpose.” — Ken-
tucky ^ledical Journal, September, 1921.
DEAD AND WOUNDED IN GERMAN EMPIRE
IN WORLD WAR
Dead
Wounded
Total
%
of Total
.•\rmv ..
1,773,700
4,216,058
5,989,758
99
Navv ....
34,845
31,085
65,930
1
Total ....
......1,808,545
4,247,143
6,055,688
100
— Medico-Military Review.
DANGERS TO X-RAY OPERATORS
The death of Dr. Ironside Bruce, radiologist to
Charing Cross Hospital, London, from the effects of
constant operation of x-rays has called attention to
a danger hitherto unsuspected. The recognized dan-
gers have been the development of malignant skin
disease from over exposure to the radiations. The
risk has been in large measure overcome by the
employment of protective measures. The heretofore
unrecognized danger appears to be due to the use of
deeper penetrating radiations, particularly affecting
the blood forming cells. Dr. Bruce died of a form of
anemia known as aplastic, which has been found to
occur in persons who have never used x-ray but there
is reason to believe that the disease occurs most
frequently in x-ray operators and is intractable to
treatment. How aplastic anemia is brought about is
uncertain, different views are held. It may be due
in some cases to the radiations themselves. In other
cases it is believed that the production of nitrous
oxide in the air Iiy the electric discharges. It is quite
clear at least that the vitiated air brings about a
state of fatigue well known to x-ray operators in re-
stricted spaces.
The danger is the greater because it is a hidden
one. The manifestations being a growing weakness
followed in some cases with death.
Researches are being conducted to determine
means of safety, which are highly important in view
of the rapid development of x-ray work.
PAY CLINICS
The board of trustees of the A. M. A. at a meeting
held November 10-12 considered the question of pay
clinics as follows:
The question of pay clinics, diagnostic clinics and
group practice was given extended discussion and a
special committee was appointed to report during the
present meeting. This committee met and considered
the subject from every point of view. The general
consensus of opinion was that pay clinics have come
into the field to remain permanently; that it is the
duty of the association to study the subject and to
offer fundamental principles and policies which
should be followed in the conduct of such clinics,
group practice, and diagnostic clinics. The principles
deemed basic are: (1) that patients should be re-
ceived by the clinic only when sent by the family
COME HELP TO MAKE THE ATTENDANCE 1000
158
Journal of Iowa State Medical Society
physician or received with his knowledge and ap-
proval; (2) so far as feasible the patient should be
returned to the family physician with written inform-
ation and suggestions; (3) that the fee charged by
such clinic should not be less than that usually
charged in general practice, so that, as far as possi-
ble, competition of the clinic with the general prac-
titioner should not occur, and the chief consideration
should be the public and the medical profession. It
was finally decided that the executive committee and
the general manager should secure a commitLee of
three, if possible, to make a survey of certain existing
diagnostic clinics and private groups, for the purpose
of obtaining full information of the methods of ad-
ministration and policies under which such institu-
tions are conducted, and report to the board at the
February meeting. — Journal of the A. !NI. A., Novem-
ber 26, 1921.
INCREASED COST OF LIABILITY
INSURANCE
An increase of 200 per cent in the cost «f physi-
cians’ liability insurance has been made by the com-
panies writing policies of this nature within the past
three months. The companies claim that they have
been losing money at the old rate of fifteen dollars
for the regular five to fifteen thousand, dollar policy.
This increase comes at a time when every one is
feeling the business depression now on us, a depres-
sion which affects physicians as keenly as any other
class or profession.
.\ssuming that the companies are correct, this in-
crease means that more people are suing physicians
for real or fancied damages — possibly more are get-
ting verdicts. It is doubtless a continued develop-
ment of the epidemic of hold-up and highway rob-
beries with which our entire country has been af-
flicted recently. At any rate it is a matter for se-
rious consideration when the cost of protection goes
from fifteen dollars to forty-five dollars at one jump.
— Virginia Medical Monthly, July, 1921.
NEW YORK HOSPITALS
Forty-six hospitals in New York, classed as non-
municipal, face an aggregate deficit of more than
$3,000,000 next year, according to the annual report
of the United Hospital Fund. The deficit is due to
the increased cost of maintenance, particularly of
free wards. — (New York ^ledical Journal.)
LIFE OF COLLEGE-BRED WOMEN
I
College-bred women live longer than uneducated
according to a study made by Myra M. Hulst of the
American Red Cross. The death rate among college
graduates between the age of twenty-five and thirty-
four was 2.77 per one thousand, but it was 6.10 for
women in the general population.
[April, 1922
THE PACIFIC NORTHWEST MEDICAL ASSO-
CIATION
We are informed by Northwest Medicine that a
movement is on foot to organize an association to be
known as the Pacific Northwest Medical Association,
to include the states of Oregon, Washington, Idaho,
Utah, ^lontana and the Province of British Colum-
bia, and other provinces if they desire to participate.
“The purposes of this organization shall be to unite
the profession of the Pacific Northwest and to bring
to the physicians and surgeons of this section the
latest Eastern thought in medical progress.’’
AMERICAN PHYSICIANS HONORED
The Royal College of Physicians of Edinburgh has
recently conferred membership on Admiral William
C. Braisted, Washington, D.C., and Dr. Walter L.
Bierring, Des Moines, two prominent members of
the National Board of Medical Examiners. This
honor is in recognition of the efforts of the National
Board in promoting a closer relationship between the
old world and the new in matters of medical educa-
tion. These are reported as the only honorary' mem-
berships conferred by the college referred to since
1809. — Journal of A. M. A., November 26, 1921.
ADVERTISING IN MEDICAL JOURNALS
The medical journals that really wanted to serve
the profession first of all have served themselves by
doing so. Witness the advertising pages of the
better medical journals for the proof of this, and
the rapidly thinning pages of the old type of com-
mercial journal. The prominent and splendid lay
journals are possible only because they adopted
the modern views on truthfully advertising goods
for which there is a legitimate demand. These same
magazines are serving their subscribers in their ad-
vertising pages. So are the high-grade medical
journals. It is becoming increasingly difficult for
the low-grade commercial medical journals to sur-
vive. This is exactly as it ought to be and there
is no valid reason why an eminently professional
and ethical medical publication should not run just
as many pages of clean and service-giving advertis-
ing as it can get to run. Most doctors appreciate
this fact. — (Medical Council.)
CHICAGO PHYSICIANS HONORED
Dr. Ludwig Kektoen had conferred on him the
honorary- degree of doctor of laws at the Centen-
nial Celebration of the University of Cincinnati.
Dr. Dean Lewis and Dr. Edward O. Jordan re-
ceived the degree of doctor of science at the same
time.
North Dakota has a committee on medical his-
tory which made preliminary report at the meeting
at ^linot, June 14, 1920.
VoL. XII, No. 4]
Journal of Iowa State Medical Society
159
LIFE EXPECTATION
According to a bulletin recently issued by the
Metropolitan Life Insurance Co., the health condi-
tions prevailing among the wage earning groups of
the United States and Canada for the first quarter
of 1921 were the best that ever have obtained during
this season of the year. The span of man’s life is
now “three score years and fourteen,” according to
Dr. George W. Hoglan, secretary of American In-
surance Union. Dr. Hoglan says careful investiga-
tion shows the average life has been lengthened four
years, in spite of added risks and perils of the twen-
tieth century. — Boston Medical and Surgical Journal
LOSSES IN THE PROFESSION IN ITALY
DURING THE WAR
The Riforma Medica cites recently published sta-
tistics to the effect that 1,060 members of the
medical and nursing professions in Italy died from
wounds or illness contracted at the front. This in-
cludes 317 army physicians, 10 in the navy, 42 of the
Red Cross service and others in the merchant
marine, to a total of 377 registered physicians. There
were also 216 medical students killed and 40 phar-
macy students, 23 veterinarians and 22 veterinary
students. Orderlies, nurses and others bring the
total to 1,060, and 300 of this number had been dec-
orated for special gallantry or devotion or both.
Of the 377 physicians, 30 died in prisons in Austria-
Hungary or Germany, or at the front in Macedonia,
Albania or Lybya. — (The Journal of the A. M. A.)
MEDICAL NEWS NOTES
Following a precedent established by Blackhawk
county some time ago, the duties of the Mahaska
county physician are to be assumed by the entire
membership of the Mahaska County Medical As-
sociation.
Members of the association will handle county
cases as physicians and surgeons in a manner to be
chosen by that organization.
Ordinary county cases will be rotated within the
membership and specialists will be in charge of spec-
ial cases.
When occasion demands experts are to be brought
here at no additional expense to the county, and
county patients given the best treatment procur-
able.
For this service the association will receive $1,200
annually, payable at $100 per month.
The county reserves the right to cancel the con-
tract any time the service proves unsatisfactory.
To assure the legality of the move the board con-
tracted with Dr. F. A. Gillett, “and others” — the
others being the following members of the county
association: Drs. F. J. Jarvis, E. M. Williams, W. S.
Windle, C. J. Lukens, B. O. Jerrel, R. M. Gillett,
P. iM. Day, J. E. Morgan, J. C. Barringer, F. A.
Ruan, B. G. Williams, C. A. Abbott, L. A. Rodgers,
S. W. Clark, C. N. Bos and E. B. Wilcox.
Under the terms of the contract the association
will furnish medical and surgical care and treat-
ment, drugs and dressings for county patients, ex-
cepting those in hospitals, pest houses, detention
hospitals and the county home.
The county will furnish the x-ray work.
The membership too, will advise and represent
the county and state in all criminal and damage cases
at no additional e.xpense, save ordinary witness fees,
and will not enter the employ of those opposed to
the county or state without the permission of the
county.
The association succeeds Dr. K. I. Johnston as
county physician.
The physicians of Cherokee count}' have agreed
to do all of the county work for $3,500. They are
subject to call by the poor at any time and agree
to respond. The contract is unique in Iowa.
Dr. W. A. Rohlf, Waverly, was re-elected presi-
dent of the Medical Life Insurance Company of
America at the second annual meeting held at the
Hotel Russell-Lamson. W. F. Getsch, Nashua, was
elected vice-president and chairman of the board;
Dr. C. E. Dakin, Mason City, vice-president; Dr.
J. E. Brinkman, Waterloo, vice-president; J. V.
Gregory, Parkersburg, chief counsel; H. W. Wil-
helm, president of the Beaver Valley State Bank,
Parkersburg, treasurer; E. L. Rohlf, Waterloo, chief
medical director; I. G. Londergan, Waterloo, secre-
tary and general manager.
This company received license to do business Au-
gust 13, 1921, and wrote the first policy September
7, the same year and since that time have put on the
books over one-half million dollars of paid for and
accepted business. Over $300,000 pending busines.«
upon which applications have been received will be
closed in the near future.
This company which has its home office in Wat-
erloo is at the present time operating only in Iowa
but plans have been completed for branches in
Missouri, Minnesota and South Dakota.
The following board of directors was also elected
at this meeting: W. A. Rohlf, Waverly; E. L.
Rohlf; Waterloo; I. E. Brinkman, Waterloo; H. W.
Wilhelm, Parkersburg; J. V. Gregory, Parkersburg;
W. F. Getsch, Nashua; I. J. Londergan, Waterloo;
W. H. Ross, Waterloo; W. H. Rendleman, Daven-
port; G. N. Ryan, Des Moines; J. B. Miner, Charles
City; F. A. Blardmore, Charles City; G. F. Heitz,
Charles City; C. E. Dakin, Mason City; I. W. Rown-
tree, Waterloo; E. G. Meir, Nashua; J. E. Ridenour,
Waterloo; A. A. Hoffman, Waterloo; L. H. Goodale,
Nashua; F. E. St. Clair, Hampton, and F. A. Haffa,
Waterloo.
160
Journal of Iowa State ^Medical Society
[April, 1922
SOCIETY PROCEEDINGS
Boone County Medical Society
The Boone County Medical Society held their
regular meeting Tuesday evening, January 31 in the
Chamber of Commerce rooms. The topic up for
discussion was Pneumonia. The out of town mem-
bers of the society who were present included Dr.
Ganoe and Drs. Clark and Clark of Ogden.
Calhoun County Medical Society
Rockwell City physicians are entertaining the
members of the Calhoun County Medical Society
and physicians from surrounding counties in Rock-
well City January 19. A feature of the session was
an address bj- Dr. Frank E. Sampson of Creston,
noted authority on public health matters. Dr. Samp-
son will address a public meeting at the court house.
Everyone is invited to hear his lecture on Commun-
ity Health.
Cerro Gordo County Medical Society
Meeting of the Cerro Cordo County Medical So-
ciety was held in the Chamber of Commerce rooms.
Mason City, Tuesday evening !March 21, 8:00 p. m.
Twenty members were present and after a short
business meeting the following program was given:
Tonsillectomy in the Treatment of , Systemic Dis-
ease, by Dr. Wilbur L. Diven. Discussion was
opened by Dr. C. E. Cheneweth.
Indications for Surgical Interference in Chronic
Otitis Media, by Dr. H. D. Fallows. Discussion fol-
lowed by Drs. F. G. Carlson, C. E. Cheneweth and
W. L. Diven.
W. L. D., Secy.
Davis County Medical Society
The Davi| County Medical Society met Monday
night January 30, 1922, and enjoyed an excellent pro-
gram on the subject of Scarlet Fever.
Officers for the year 1922 were elected as follows:
President, Dr. J. G. Stone; vice-president, Dr. C. C.
Heady; secretary-treasurer. Dr. H. C. Young.
Dr. Stone was selected as delegate from the county
society to attend the state medical association con-
vention. Dr. H. C. Finch of Pulaski was selected
as alternate.
The subject of the next program will be Pneu-
monia. Dr. C. D. Skelton will conduct the program,
having had a recent personal experience with the
disease that makes him peculiarly informed and
fitted to treat the topic from all angles, that of the
patient as well as that of the physician.
Hamilton County Medical Society
The Hamilton County ^ledical Society met at the
Willson Hotel January 31 for a 7 o’clock dinner
and program.
Dr. R. A. Weston, Des Moines, guest at the meet-
ing, presented a paper on Indications for Nephrec-
tomy in Renal Stone. The talk was illustrated with
x-ray plates. Following Dr. Weston the subject was
discussed by Drs. McCauliff, W. W. Wyatt, R. C.
Crumpton, C. J. Reed, E. W. Slater and R. M.
Wildish.
Dr. M. B. Galloway presented a case of Cardio
Spasm of the Esophagus. He gave a discussion of
the condition and a demonstration of the method of
treatment.
Fifteen members attended the meeting. The next
meeting of the societj' will be held February 20.
Linn County Medical Society
The largest meeting of the Linn County Medical
Association ever held was that at Hotel Mont-
rose January 16 when more than 100 members of the
profession heard two noted physicians. Dr. Cassins
C. Rogers of Chicago, and Dr. Hugh Cabot, profes-
sor of surgery at the University of Michigan, speak
Dr. David E. Beardslej% president of the organiza-
tion, introduced them.
Physicians from Cedar Rapids, neighboring towns
of the county, Waterloo and Des Moines were in at-
tendance.
Following the program there was a buffet lunch-
eon served, at which Drs. Krause, Petrovitsky,
Houser, and Welch were the hosts.
Mahaska Medical Association
Incorporation papers have been filed with County
Recorder Frank J. Evans by the Mahaska Aledical
Association and signed by Drs. F. J. Jarvis, S. W.
Clark, S. W. Hartwell, E. M. Williams, F. A. Gil-
lett, C. A. Ayres, K. L. Johnston and C. N. Bos.
The articles of incorporation were executed Feb-
ruary 1, 1922, and provide for both active and hon-
orary members and the association is organized for
the purpose of advancement in medical science and
the promotion of public health and hygiene.
The annual meeting is designated as the first Tues-
day in January in each year and the officers are a
president, vice-president, secretary and a treasurer,
as well as a board of trustees and a board of censors.
The officers elected for the first year are: Presi-
dent, F. I. Jarvis; vice-president, J. A. Ruan; secre-
tary, F. A. Gillett, and treasurer, B. O. Jerrel. The
trustees are S. W. Clark, K. L. Johnston and E. ^I.
Williams. The board of censors are B. O. Jerrel, S.
W. Clark and F. J. Jarvis.
The officers are elected each year by the members
and the ones selected for the board of trustees and
the board of censors are elected for three years.
Pottawattamie County Medical Society
Pottawattamie County Medical Society held a com-
munity medical discussion at ^lercy Hospital Tues-
day, January 24. A luncheon in connection with the
meeting at 12:30 o’clock.
The following is the program arranged:
Dr. A. V. Hennessey, Council Bluffs, Hyper-
nephrona. Presentation of a case.
VoL. XII, No. 4]
Journal of Iowa State Medical Society
161
Dr. T. B. Lacey, Glenvvood, Mongolianism. Il-
lustrated by x-ray plates. Presentation of cases.
Dr. William Jepson, Sioux City, subject not an-
nounced.
Prof. S. G. Alcock, Iowa City, The Diagnosis of a
Chancre; Its Importance and Technique.
Prof. C. P. Howard, Iowa City, The Differential
Diagnosis of Jaundice.
Present officers of the society are: Dr. M. E.
O'Keefe, president; John McAtee, vice-president,
and Dr. A. A. Robertson, secretary. The program
reorganization committee is composed of Dr. Don
Macrae, Jr., G. A. Spaulding and M. E. O’Keefe.
Wapello County Medical Society
The Wapello County Medical Society, which held
its regular monthly meeting March 7 at the office oi
Dr. A. O. Williams, was presented with a gavel, a
gift from Captain H. A. Spilman. The gavel, which
is silver mounted, is made of koa wood, a hard na-
tive wood much used in Hawaii.
Captain Spilman, who is the son of Dr. S. A. Spil-
man is a member of the regular army medical corps
and for the past year and a half has been stationed
in Honolulu.
The principal speaker at the meeting, at which Dr.
F. W. !Mills, presided, was W. H. Powell, managing
editor of The Courier. His subject was Quacks and
Cure Alls.
Scott County Medical Society
Pneumonia, followed by an open discussion fea-
tured the meeting Tuesday, February 7 of the Scott
County Medical Society _ held in the Davenport
Chamber of Commerce. Drs. George Braunlich, L.
H. Kornder, W. H. Rendleman, F. Lambach and H.
Meyers gave informal talks, after which Drs. F.
H. Lamb, J. E. Rock and L. Guldner took part in
the discussion.
Davenport Radium Institute
Officers were elected at the annual meeting yes-
terday of the Davenport Radium Institute held in
the office of Dr. W. H. Rendleman when the follow-
ing were named to serve: President, Dr. W. H.
Rendleman; vice-president. Dr. F. J. Otis, Moline;
secretary. Dr. P. A. White, Davenport; treasurei.
Dr. B. H. Schmidt, Davenport.
The board of directors were re-elected and consist
of the above named and Dr. J. W. Seids of Moline,
Dr. D. B. Freeman of ^Moline and Dr. S. G. Hands
of Davenport.
It was reported that the institute is expanding
satisfactorily, over forty cases having been treated
and the members voted to buy another twenty-five
milligrams of radium swelling the amount of its
stock to 100 milligrams. It was voted to employ a
full time nurse.
Iowa Clinical Surgical Society
Dr. E. Starr Judd and W. F. Braasch of the Mayo
Brothers’ Hospital at Rochester, Minnesota, are
among the distinguished surgeons who attended
the clinic of the Iowa Clinical Surgical Society at
the Iowa Lutheran Hospital recently.
Other surgeons of note present in the city for the
clinic are Drs. Dean Lewis and Hopkins, chief sur-
geon of the Northwestern Railroad Company of
Chicago, and Dr. John E. Summers of Omaha.
The clinic is being conducted by Dr. Charles Ryan,
Dr. J. C. Rockafellow, Dr. O. J. Fay, Dr. Wilton
McCarthy and Dr. W. W. Pearson.
The surgical society has a membership of about
twenty-five surgeons, and has as its president Dr.
Wilton McCarthy, with E. R. Shannon of Waterloo,
secretary.
Surgical operations were performed this morning,
and discussion occupied the afternoon hours. The
organization meets four times a year at various
places in the state.
Delicate surgical operations requiring the most
expert technique were performed at Iowa Lutheran
Hospital January 28, 1922, by members of the Iowa
Clinical Surgical Society at the first of their three
annual meetings held there. Twelve operations were
performed by the visiting surgons.
Officrs for the present year were elected as fol-
lows;
Dr. P. B. Mcl.aughlin of Sioux City, president;
Dr. W. A. Rolf, vice-president; Dr. E. R. Shannon,
secretary and treasurer. Dr. Wilton McCarthy of
Des Moines, the retiring president.
Three prominent surgeons from outside the state.
Dr. J. Hollowbust of Rock Island, Illinois; Dr. J. L.
Summers of Omaha, Nebraska, and Dr. G. G. Cot-
tam of Sioux Falls, South Dakota, were guests of
the society at the clinic.
Members of the society and local physicians to
the number of forty-five were dinner guests of Dr.
W. W. Pearson last night.
Following a brief business session Friday night at
the White House Club, East Twenty-ninth street and
Madison avenue, the members were entertained by
Drs. W. W. Pearson, Charles Ryan, R. A. Weston
and Wilton McCarthy. — Des Moines Register.
TUBERCULOSIS CLINIC
All physicians in attendance at the annual meeting
of the Iowa State Medical Society will be interested
in a tuberculosis clinic to be held in conjunction
therewith on the afternoon of Friday, May 12, under
the auspices of the Iowa Trudeau Society which is
affiliated with the Iowa Tuberculosis Association.
Arrangements have been made to bring to Des
Moines for this occasion George Thomas Palmer,
M.D., of Springfield, Illinois, well known tuberculo-
sis specialist, and president of the Illinois Tuberculo"
sis Association.
Secure Your Hotel Reservations at Once— For Hotels, See Advertising Pages iv, vi, and viii
162
Journal of Iowa State Medical Society
[April, 1922
A. M. A. NEWS
The seventy-third annual session of the American
Medical Association will be held in St. Louis, May
22-26, 1922, and the committee on arrangements re-
port an unprecedented prospect for a large attend-
ance.
Hotels
All fellow members expecting to attend, should
write at once to the hotel of their choice or their
section hotel, or Dr. Louis H. Behrens, 3525 Pine
street, St. Louis, Chairman Hotel Association and
Convention Bureau.
Passenger Rates
The passenger rates for round trip will be one and
one-half fare certificate plan, and one certificate will
enable the member to purchase tickets for himself
and for dependent members of his family.
The certificates are now ready for distribution and
can be secured by writing to Dr. Alexander P..
Craig, secretary of the American ^ledical Associa-
tion, 535 North Dearborn street, Chicago, enclosing
a self addressed, stamped envelope.
J. W. Cokenower, M.D.
HOSPITAL NEWS
Miss Laura Parker, superintendent of Eleanor
Moore County Hospital, Boone, has resigned to en-
ter another branch of work.
Miss Beatrice Case of the Washington County
Hospital has been elected superintendent of the
Eleanor ^loore County Hospital, to succeed Miss
Laura Parker who has taken up private work.
Sigourney's new hospital, which for a number of
weeks has been in the process of overhauling, and
rebuilding was opened for patients a few days ago.
It is under the management of Drs. Heald and
Pfannebecker.
Mrs. Elizabeth Flynn of Davenport was re-elected
president of the Sixth district of the Nurses’ Asso-
ciation of Iowa, at the annual meeting of the associa-
tion held January 19 at the public library club rooms.
Mrs. Edna Atkinson was re-elected secretary and
Miss Ruby Beal was elected treasurer. Two very
interesting addresses were given by Dr. L. H. Korn-
der and Dr. Sara Foulks of Davenport. Dr. Kornder
spoke on The Psychology of the Sick Room and Dr.
Foulks gave an account of her experiences in Turkey
where she was doing Red Cross work. The president
read splendid reports of the Iowa state convention
which was held in Iowa City in November. There
was a fairly good attendance at the meeting.
Dr. B. F. Weston heads the staff of St. Joseph’s
Mercy Hospital, Mason City, for the coming year
He was appointed to the office at the annual ban-
quet and meeting of the staff members held at the
hospital ^londay evening. Other officers appointed
are: Dr. R. E. Brisbine, vice-president, and Dr. J. E.
Marek, secretary and treasurer.
Committees appointed include the executive com-
mittee, Dr. S. A; O’Brien, chairman; Dr. E. Henely,
Dr. S. S. W estlj’ and two Sisters of Mercy and
record committee, Dr. Raymond Weston, chairman.
Dr. C. A. Hurd and Dr. F. G. Carlson. Heads of
departments are: Dr. G. S. Westly, medical depart-
ment; Dr. Raymond Weston, surgical department;
Dr. S. A. O’Brien, specialists’ department, and Dr.
J. W. Kelly, dental department.
New impetus to a movement inaugurated by Clear
Lake physicians for the establishment of an adequate
and modern hospital in this city was given recently
with the announcement that Dr. J. A. Swallum would
donate a peculiarly fine site on his lake front prop
erty for this purpose, the value of which is con-
servatively estimated at $4,000 and six other local
physicians, Drs. E. F. Smith, J. H. O’Donoghue, H.
E. Farnsworth, A. G. Gran, E. D. Banghart and U. S.
Parish, each pledged $1,000 to the cause. — Storm
Lake Tribune.
Friday afternoon, February 3, a meeting of the
members of the Ogden hospital was held at the city
hall for the purpose of electing new officers.
Following is the result: President, Henry Klip-
pel; treasurer, W. M. Rosen; secretary, Mrs. Wm.
Jons; board of trustees, T. E. Beck, C. H. Williams,
Mrs. C. Thomas, Mrs. Alvin Treloar, Mrs. E. Rock-
well and C. E. Cook.
“Sarton Hospital,” gift to the city (Cedar Falls)
through bequest of the late Joseph Sarton, Sr., and
contribution by his son, Joseph Sarton, Jr., “is not a
charitable institution and takes no charity patients,”
according to H. S. Gilky, vice-president of the hos-
pital board.
We are also informed that this hospital receives
a millage tax of from $4,000 to $4,800 per year.
This is the only hospital of the kind in the state,
unless it be some private hospitals. We are led to
infer that there are no poor people in Cedar Falls,
or if there are, they are left to care for themselves.
We trust that the brutal quotation above noted does
not fairly represent the sentiment of what we have
supposed to be a city of high ideals.
A judgment of $15,000 was awarded Robert Stine
of Indianapolis, against the St. Vincent Hospital of
Indianapolis b}' a jury in the Hendricks circuit court.
The jury was out less than twenty minutes, and it
awarded the full amount sought in the suit.
Mr. Stine was a patient at the hospital in March,
1917. According to the testimonj-, after undergoing
an operation he was placed in a ward where, while
still unconscious, a nurse laid a hot water bottle on
his left foot and left him. His foot was so badly
burned that amputation was necessary a few week>
later, it was testified.
VoL. XII, No. 4]
Journal of Iowa State Medical Society
163
Attorneys for the hospital filed a demurrer to the
complaint, setting forth the argument that the hos-
pital was a charitable institution and therefore not
liable for damages. Judge Dougan overruled the
contention and excluded evidence that the hospital
property was not listed for taxation in Marion
county.
— Indianapolis Medical Journal.
Miss Adele Northrop, superintendent of Finley
Hospital, has announced that a series of lectures on
medical subjects would be given at the hospital on
Thursday afternoons at 4:00 o’clock. The subjects
chosen are those of particular interest to the public
and are similar to those given at the larger hospitals
throughout the country. The object of the lectures
is to give the public fundamental knowledge of the
early characteristics of certain diseases so that they
may know how to detect them in early stages, have
them treated and prevent an incurable condition.
The following is the list of the topics and the dates
they will be given:
March 9 — What the Public Should Know About
Cancer — Dr. E. P. McNamara.
March 16 — How the Public Health Laboratory
Protects Your Health — Harold A. Grimm.
March 23 — What an Adequate Diet Means — Mary
Cunningham.
March 30 — Diphtheria: Detection: Modern Treat-
ment: Prevention: Demonstration of Schick Test —
Dr. F. P. McNamara.
April 5 — The Nurses’ Training School as a Com-
munity Asset — N. Adele Northrop.
.\pril 13 — Holy Week — No lecture.
April 20 — Are You Getting What You Pay For? —
Harold A. Grimm.
April 27 — What Hospital Standardization Cleans to
the Community — Dr. F. P. iIcNamara.
The board of directors of the Community Hospi-
tal, Grinnell, tendered a banquet to the newly elected
medical staff at Hotel Monroe Saturday evening,
February 25.
Several medical men were in from surrounding
towns. After a very enjoyable social time Chairman
Kiesel of the board called the company to order and
expressed to the physicians present that it was de-
sired that they organize and appoint a committee to
frame hospital rules to be submitted to the board for
approval. Dr. O. F. Parish was elected chairman of
the staff. Dr. E. B. Williams of Montezuma, vice-
chairman and Dr. P. E. Somers, secretary. A very
free, frank and informal discussion was participated
in by every one present with the result that there was
a practically unanimous opinion as to the principles
and policies to be pursued in the management and
conduct of the hospital. Every one was enthusiasti-
cally hopeful as to the outlook and usefulness of the
hospital as one of the greatest assets to Grinnell
and Poweshiek county. A number of phj'sicians
elected to the staff were away from home and un-
able to be present. Those present were, of the board
of directors, F. 1. Kiesel, H. S. Lowrey, Dr. O. H.
Gallagher, G. O. Watland and W. C. Wasscr.
The following doctors also were present: C. H.
Lauder, O. F. Parrish, L. L. Gould of Kellogg, G. B.
Ward of Gilman, C. D. Busby of Brooklyn, L. A.
Hopkins, J. R. Lewis, P. E. Somers, W. W. Hansell.
PERSONAL MENTION
Dr. Hamstreet of Clear Lake has purchased the
practice of Dr. Clapsaddle who expects to enter the
government service at Philadelphia, Pennsylvania.
Ten thousand dollars in damages is asked of Dr.
W. H. Bickley of Waterloo by Rose Curry, widow
of Hugh Curry, who died after being struck by an
automobile owned by the Doctor February 4 on
Rainbow drive. The petition charges that at the
time of the accident which resulted in Mr. Curry’s
death, the car was being driven by Demetri Subeff,
Dr. Bickley’s chauffeur. Dr. Bickley was at that time
in Chicago. Subeff had taken Elias Bickley, the
Doctor’s father, to Hudson for a visit. While there
Subeff took three of the Hendry children for a ride.
It was while on this drive that they overtook Mr.
Curry who was walking on Rainbow drive. He was
run down and fatally injured. There were conflict-
ing stories as to who had the wheel when Curry was
struck, although all say Alonzo Hendry took the
driver’s seat at Electric park. The petition claims
that Mr. Curry was not guilty of negligence. It i.*^
claimed that at the time of the accident Subeff was
in charge of the car and that he was the agent, ser-
vant and employe of the owner of the car. The com-
plaint states that the collision with Curry was the
proximate result of the negligence of Subeff. In-
terest in the Curry family is best gauged by the con-
tributions made by people of Waterloo and sur-
rounding towns. Hudson people raised a purse of
about $115.
Dr. F. 1. McAllister, who with his family has been
in Los Angeles since last August, has written Dr.
A. J. Meyer recently that the condition of his health
has shown such marked improvement during the
past few months that he expects to be able to re-
turn to Hawarden this spring and resume active
medical practice
Dr. Eva M. Blake, national Y. W. C. A. secretary,
who gave a series of lectures recently to the girls of
Drake University, Des Moines, Iowa, is the inspira-
tion for a number of social courtesies. Monday
night, March 6, Dr. Blake was a dinner guest at the
home of Dr. Sophie Hinze-Scott, 1300 East Grand
avenue, who entertained the club of women physi-
cians. Dr. Jeanette Throckmorton was also a, club
guest. Covers were arranged for Doctors Helen
Johnston, Mary Hurd, Nelle Noble, Alice Humphrey
Hatch, Grace Doane, Ella Gray, Mae Habenicht,
Jennie Coleman and Mrs. Daniel Glomser.
Dr. C. S. Short of Chicago, is expected today to
join the Dr. Bamford clinic. He takes the place
vacated by Dr. V. E. Dudman who left Wednesday
164
Journal of Iowa State Medical Society
[April, 1922
for Portland, Oregon. Dr. Short has been specializ-
ing in internal medicine and obstetrics, which will
be his main practice here.
At the annual meeting of the medical section of
the American Life convention, held at French Lick
Springs, Indiana, March 1, 2 and 3, Dr. G. E. Craw-
ford medical director of the Cedar Rapids Life In-
surance Companj^ was unanimously elected pres-
ident of this body for the coming year. The Ameri-
can Life convention is composed of a membership of
about 120 of the leading old line insurance compan-
ies in the L'nited States. The medical section is a
very important part of the association and they hold
their own convention each year.
The physicians who are to occupy the new $80,000
Clinic building at the corner of First avenue north
and Tenth street. Ft. Dodge, are moving their office
furnishing today into their new quarters. The
building is not yet complete in some details of dec-
orating, etc., but sufficiently complete for the doc-
tors to carry on their practices. In a week or two
they will have an official opening. The men who are
moving in today are Drs. A. M. McCreight, A. A.
Schultz, E. F. Beeh, S. D. Jones, S. B. Chase, J. F.
Studebaker, T. J. Foley and C. G. Field. ,
Dr. William Bruff of Atlantic sails early in Feb-
ruary for Seonl Korea where he will teach bacteri-
ology in Serrerance, accompanied by his wife and
son Joseph.
Dr. M. F. Smith of Wesley has moved to Britt
where he will practice medicine. Dr. Smith served
in the L^. S. Medical Corps overseas with the rank
of captain.
Dr. Park Findley, veteran of the Spanish-American
War, the Filipino insurrection and the World War,
has announced himself as a candidate for the re-
publican nomination for sheriff, Polk county.
Dr. L. G. Patty has closed his office at Carroll and
become connected with the Carroll Clinic as sur-
geon.
Fontanelle friends are advised of the arrival in this
country of Dr. W. H. Bell, Fontanelle, on his return
from a long service with the Red Cross in Turkey.
Dr. Bell spent two and a half years in Turkey, ren-
dering such meritorious service that he was dec-
orated by the Turkish government. He was director
at different times of hospitals at Smyrna and at
Narash. On leaving Turkey Dr. Bell toured through
Palestine, Syria, Egypt, India, Philippines, China
and Japan.
Dr. Ralph W. Mendleson, formerly of Des Moines,
according to word received here, has been decorated
recently^ by the government of Siam with the Order
of the White Elephant and by Serbia with the Or-
der of St. Sava. For the past six years Dr. Mendel-
son has been connected with these governments in
sanitation work.
Dr. M. F. McMeel of Lost Nation, Iowa, has
moved to Clinton and secured office rooms in the
Wilson building.
We are informed through the daily' press that
Dr. D. C. Brockman and Dr. S. A. Spillman of Ot-
tumwa were the guests of honor at a banquet given
by' the Wapello County' Medical Society', February-
28, Dr. Charles B. Taylor, toastmaster.
OBITUARY
Dr. W. E. Grigsby, prominent Burlington phy'sician,
passed away January' 7, 1922, at 8:30 o’clock in his
home, 807 South Central avenue. He had been ill
only' a week. He was stricken with a severe attack
of apoplexy and Dr. Campbell, who had been attend-
ing him was summoned. When he arrived at the
home, the patient was dead.
Dr. Grigsby was born near Bardstown, Kentucky',
in 1862 and was fifty-nine years old. He was a man
of exceptional ability and a graduate of two medical
colleges. He had taken post graduate courses in
New York, Chicago and Louisville.
He came to Burlington to practice his specialty in
1917. He is survived by his wdfe, daughter and a
brother.
William L. Crowder of Deep River was born No-
vember 16, 1840, in Sangamon county, near Spring-
field, Illinois. In 1843 he came with his parents to
Iowa and lived on a farm in Mahaska county until
he was sixteen years of age, when they moved to
Oskaloosa. After completing the public school
course he studied medicine in the office of Dr. F. M.
Coolidge from 1860 to 1864 and then’ took a year’s
course of leptures in Rush Medical College. Return-
ing to Iowa he located at Springfield in Keokuk
county where he practiced medicine from 1865 to
1876, with the exception of one year which he spent
completing his medical course at Rush ^ledical Col-
lege, from which institution he graduated in 1870.
In 1876 he moved to Rose Hill where he practiced
his profession until 1884 when he moved to Oska-
loosa and there continued his medical practice until
1910 whe he retired. He continued to live in Oska-
loosa until the fall of 1918 when he moved to Deep
River and made his home with his daughter, Mrs.
C. N. Cox where after a brief illness he passed away'
February 9, 1922, aged eighty-one years, two months
and twenty-four days.
Dr. John Nevins of Butler died at his home July
25, 1921, of diabetes. He had practiced in Butler
forty years. Three years ago he retired from prac-
tice and had been confined to his house and bed for
several months. Dr. Nevins w'as a member of his
county medical society and the Iowa State Medical
Society.
Dr. Charles Montgomery Wade, fifty-four years
old, prominent Sioux City physician, and resident of
Sioux City since 1893, died at 3:30 o’clock February
5 at his residence, 1010 Tenth street.
The veteran physician was born at Stanwood,
Iowa, April 28, 1868, and was the son of Mr. and
Mrs. John I. Wade. He attended the country
VoL. XII, No. 4]
Journal of Iowa State Medical Society
165
schools and spent the early part of his life at Stan-
wood.
Several years later he entered the Iowa State Col-
lege at Ames and was graduated in 1889. The next
year he returned to the college and took a post
graduate course. He also attended the medical de-
partment of the college at Iowa City. For several
years he was an instructor in both colleges.
In 1893, Dr. Wade came to Sioux City and en-
tered the medical school, formerly located in the
Methodist hospital. He taught chemistry and mathe-
matics for several years. He was graduated from
the Sioux City medical school in 1896.
For two years he practiced medicine at Castana,
Iowa. He returned to Sioux City and married. He
then took a post graduate course in the medical
school in Sioux City. In 1899 he opened his first
Sioux City office and has been actively engaged in
business ever since.
Dr. Wade at one time was president of the Sioux
Valley Medical .A.ssociation and about twelve years
ago was coroner of Woodbury county.
James W. Groom was born at Melbourne, Aus-
tralia, November 3, 1884, and died suddenly at his
office in Greene, from a hemorrhage in the brain,
on January 6, 1922, at the age of thirty-seven years,
two months and three days. He was the youngest
of a large family of fifteen children. His early life
was spent in the home of his birth. At the age of
nineteen he came to America and almost imme-
diately entered Drake University where he pursued
his medical course finally receiving his degree in
1911 and his state license on June 14 of that year.
His study at Drake was interrupted for a time by
an uncertainty as to what his life work should be.
This led him to take a course in theology at the
Texas Christian University, Waco, Texas. He later,
however, decided to become a physician in which
field he distinguished himself with splendid skill
and ability.
He came to Greene about ten years ago, imme-
diately upon the completion of his university work,
and began a practice which has steadily grown with
the years. At many times the duties that came to
him to perform overtaxed his natural vigor and
health. How frequently did he know what it was
to “Be weary in well doing” as have all true men of
his profession.
On November 3, 1919, he was united in marriage
to Bernice Kohlhass at Minneapolis. Early in De-
cember of that year he returned with his bride to
Australia to enjoy that happy reunion with friends
and relatives. A joy that was not without its tinge
of sorrow for both the aged father and mother had
passed away a few years previously.
They returned to America in April, 1920, when he
again resumed his practice in Greene. He leaves
no relatives in America except his wife and little
thrfee-months-old daughter, Shirley.
It was a matter of deep satisfaction to the de-
ceased to be able, after a long series of delays, to
COME HELP TO MAKE
get his final papers admitting him to citizenship in
the United States. This was accomplished in Sep-
tember of last year.
The following doctors, representing the Butler
County Medical Society, were present at the funeral;
Drs. Smith, Day and Young, Clarksville; Dr. En-
sley. Shell Rock; Dr. Hobson, Parkersburg; Dr.
Reeve, Allison; Dr. Roder, Aredale and Drs. Call,
Bigelow and Birney, Greene. Dr. C. J. O’Keefe of
Marble Rock was also in attendance and on Sunday,
Dr. John O’Keefe of Waterloo, paid his respects.
Dr. Groom was a member in good standing in the
following medical societies: Fellow of the Ameri-
can Medical Association, Iowa State Medical So-
ciety, Tri-State District ^Medical Society and Butler
County Medical Society.
Dr. William Edward Ely of Ocheyedan who died
February 12, 1922 was born March 16, 1861, in New
York City. W^ith his parents he removed to Kal-
amazoo, Michigan. He was educated in the schools
of Kalamazoo and in 1885 he graduated with a de-
gree of Doctor of Medicine from the University of
Michigan at Ann Arbor. He began practice in Bat-
tle Creek, Michigan and two years later, 1887 he
located at Ocheyedan.
Dr. Ely was married to Miss Alice Kirby of Kala-
mazoo, Michigan. Mrs. Ely passed away in Septem-
ber, 1915. No children survive.
Jesse Franklin Stong, son of Jacob and Cynthia
Stong, was born at Kilbourne, Iowa, April 18, 1874,
and died in Barada, Nebraska, of apoplexy, Febru-
ary 7, 1922. He was in his usual good health up to
within a few minutes of his death.
On October 29, 1900, he was married to Miss
Wilda Barker of Mt. Zion, Iowa, and to them were
born three children: Helen Webb, William Dean
and Robert Burns.
He graduated from the Keokuk Medical College,
class of 1900, and the following year practiced med-
icine in New Mexico. Since then, with the excep-
tion of the time spent in the World War, he prac-
ticed in Nebraska. He volunteered for service in the
medical department and was given rank of first lieu-
tenant. He was in three major engagements and
while at Argonne Forest was twice gassed.
Dr. William Henry Myers was born in Laran,
Illinois, January 26, 1858, and died in Sheldon, Iowa,
February 7, 1922, age sixty-four years and twelve
days.
He grew up to young manhood in the neighbor-
hood of Eleroy, Illinois, working on the farm and
teaching school.
In 1879 he entered Rush Medical College of Chi-
cago and graduated in February, 1882.
On June 15, 1882, he was married to Anna Eliza-
beth Richard of Eleroy, Illinois, and moved imme-
diately to Laran, Illinofs, where he practiced medi-
cine for a year and a half.
In November, 1883, he moved to Holstein, Iowa,
THE ATTENDANCE 1000
166
Journal of Iowa State Medical Society
[April, 1922
where he remained until Tune, 1884, when he moved
to Aurelia, Iowa.
In August, 1889, he came to Sheldon, where he
has since lived.
Seven children were born: Ellersle B., Brenda
Fern, Lojal Richard, ludson Wm., Gladys R., wife
of L. A. Henderson of Sheldon; Lynn L. and Mar-
garet Elizabeth, wife of Dr. F. Nelson of Sheldon.
All of the children are living except Brenda Fern,
who died at the age of fifteen.
March 6, 1922
Dr. D. S. Fairchild, Editor,
Journal of the Iowa State ^ledical Society.
My Dear Dr. Fairchild:
At the request of Dr. A. P. Stoner, president of
the Polk County Medical Society, Des ^Moines, the
surgeon general asks that if you think proper you
publish the following in an early issue of your
Journal:
“Washington, D. C., March 6, 1922. — It has sev-
eral times recently been brought to the attention of
the surgeon general’s office that a concern in Des
^Moines known as the Pulvane Laboratory has is-
sued a pamphlet and other printed matter in which
statements are made implying that the experiments
and studies referred to therein were made with the
sanction and under the direction of the medical de-
partment of the army. I wish to say that this is not
so and that the medical department of the armj^ has
not been concerned in any way with the matter, and
furthermore, that it thoroughly disapproves of the
methods employed by the promoters of this concern.
(Signed) C. R. DARNALL,
Colonel, Medical Corps, L^. S.
A., Executive Officer, Sur-
geon General’s Office, War
Department.”
I
March 2, 1922.
Dr. D. S. Fairchild, Sr.,
Clinton, Iowa.
Dear Doctor:
In the February, 1922, Journal appeared the trite
and well written article of Robert T. Morris, F.A.C.S.,
on “The Outlook for the Fourth Era of Surgery.’’
Had the word medicine been used instead of sur-
gery in the subject and the text recognized surgery
as a branch of medicine and not the whole thing this
epistle would not have been penned.
Morris appropriates the work of Pasteur, Wright
and Metchnikoff, also the discovery of anesthesia to
surgery. The department of surgery has become
most prominent during the past twenty-five years.
It is also a fact that the distrust of the medical pro-
fession by the public has become great during this
time. Quite likely surgery has been a cause, causing
a commercial atmosphere to creep into medicine,
with the fee splitting and unnecessary operation
features attending. Many surgeons forget they hold
the degree. Doctor of Medicine and that surgical
technic is all that is necessary to the business of
surgery. They over value surgery in direct propor-
tion to the way they under value all other branches
of medicine.
Dr. ]\Iorris states in closing that he cannot predict
“what the fifth or sixth eras of surgery will be.” I
hope that the fifth era will be “the safe and sane
era” of medicines and its branches, and that it will
take place real soon and last a long time.
Fraternally,
JOHN W. SHUMAN.
January 31, 1922.
Editor, Iowa Medical Journal,
Clinton, Iowa.
Dear Sir:
I wish to tell you about a recent experience of
mine; it may be instructive and helpful to others.
I am a middle aged man, always strong and healthy.
For quite a long time I have been a little constipated
and on having a hard lumpy passage would have a
sharp, tearing, stinging pain, just for a second. Then
would find a drop or two of blood on the first por-
tion of the stool, and on using the toilet paper, would
find a drop or two of bright blood. For one-half to
an hour, there would be a smarting uneasy feeling
around the orifice, then all right until the next da^^
A few months ago, I read in the paper a warning
that one with these symptoms after middle life
should be examined for possible cancer, so I took a
day off from business and went to the Metropolis
to see a famous doctor.
I told him mA' only trouble, and asked him to
examine my rectum. He at once began to take my
personal history. He dug up my entire past, measles,
whooping cough, itch, everything I ever had or
have done, age, birthplace, height, weight, vi. pre-
cipitation, temperature, etc.
He asked me if I had ever had pneumonia or been
associated with a consumptive. He found I had
never had syphilis and only the average number of
doses of clap. Then he began to pick on my grand
parents and distant relatives. Neither of my grand-
fathers were drunkards nor had grandmother had
fits. My uncles and aunts were just average normal
healthy people. Then after insulting the memory
of my parents, he began on my children, but I con-
vinced him they were all right or at least he let up
on them.
Then he looked over my eyes, ears, nose, throat,
teeth and neck, .^t this time I again told him that
my only complaint was lower down and that we
were wasting time, but he sadly but firmly told me
that “anything worth doing at all was worth doing
well.”
As it was too late now, for the early train home, I
let him have his way. He stripped me, listened OA'er
my chest, thumped me fore and aft, punched my
stomach with his fist, handled my intimate parts in
a scandalous manner. Then he pushed a long in-
strument which he called some kind of a scope up
VoL. XII, No. 4]
Journal of Iowa State Medical Society
167
into my rectum for a foot or more. Then he took
a little hammer and pounded my knees and various
parts of my body and limbs, tickled my feet and a
lot of other stunts.
I forgot to say that previous to this, he had taken
a sample of my water and had given me a glass of
water and a few crackers to eat, and also took a few
drops of blood from my ear and said something
about hemoglobin. After he let me up from the
barber chair and had me dress myself, he came with
a long rubber tube and ran it down my throat and
pumped his test meal out, and gave the contents to
the same assistant who had taken the urine for
examination.
After a while this nice looking lady came back
and reported the urine as normal only she had
found two germs of some kind. I did not learn their
sex.
The stuff from my stomach had some kind of free
acid in it. I don’t know' how it got there at all as
I had drank nothing of the kind.
Well the next thing was, that he wished to have
an x-ray of my stomach. Well as I had to stay all day
in the city anyw'ay, and he seemed to be enjoying it
all I consented. We w'ent down several stories to
his friend’s office. There they gave me a quart of
something to drink that was a poor substitute for
even home brew* and began to take observations of
my internal structures, talking in the meantime in
a low solemn manner. Then we went back up
stairs again and after finding out what I ordinarily
ate and enjoyed, and the things I loathed, he forbade
the former and prescribed the latter. He ordered
me to give up all active business, stop smoking, to
stay in bed most of the day, and to come back in
two weeks. He also recommended me to visit an
ej'C specialist whose card he gave me.
Well, I returned home a chastened sad wreck of the
sturdy man who had left so cheerfully in the morn-
ing. I forgot to say he extracted $37.50 from me
for himself and his fellow conspirator down below
But to continue I ate the things I hated, neglected
my work, tried to find where I felt the worst. Of
course the few. drops of blood still show'ed part of
the time.
Finally my wdfe insisted I should see our old
family doctor, “an old fossil,’’ said I, “he don’t know
enough to pound sand in a rat hole, even if he had
some one to hold the rat for him.’’ But I went just
the same as I always do when lane tells me to. The
old Dock bent me over a chair, pulled buttocks
apart and told me to strain and bear down. Then
he got a little stick with a wisp of cotton wound
on it, and a bottle of medicine which I saw was
marked carbolic acid, though he seemed anxious to
conceal the label. He again bent me over the chair
and told me it would hurt a little. It did, that was
no dream, it was a nightmare, but Dock said it would
feel better when it quit hurting. It did. He told
me he had not found any piles, only a fisher. 1
don’t know how this fisher got there, or what he
was fishing for.
Dock told me to come back in three days which
I did. He said I was cured and I find I am. Life is
again bright and worth living.
Yesterday I asked Dock for my bill and the old
robber said two dollars. The old fogy had not
given me twenty minutes of his time. Don’t you
think that old fossil should be put out of business
as a profiteer? Has he any right to cure a patient
in this unscientific way?
Excuse me for withholding my name as I am a
modest man, and have already been shocked enough.
Yours truly,
BOOK REVIEWS
COLLECTED PAPERS OF THE MAYO
CLINIC, 1920
Edited by Mrs. AI. H. Alelish, Rochester,
Alinnesota; Octavo of 1392 Pages, 446 Illus-
trations. W. B. Saunders Company, London
and Philadelphia, $12.00 Net.
It is a difficult task to review a book containing
such a vast amount of material covering so many
subjects. It is difficult to estimate the value of the
papers based on the great amount of material at the
Alayo Clinic, subject to every test to determine ac-
curacy. To those familiar with the methods at the
Alayo Clinic, a feeling must come that we are only
left to accept as the last w'ord, the claims set forth
in this volume.
The papers are arranged in ten divisions. Under
the head of the Alimentary Tract, are twenty titles
including 188 pages. The first paper relates to a
method of applying radium in cases of Esophageal
Cancer by Dr. P. P. Vinson. This paper is interest-
ing on account of apparent difficulties made easy,
with a hope of accomplishing something in a class
of cases otherwise beyond relief. Dr. W. J. Alayo
presents a statistical paper on Calloused Ulcers of
the Stomach, based on location of ulcer.
Dr. W. C. MacCarthy restates his position in rela-
tion to chronic gastric ulcer and carcinoma.
Following is a series of papers on gastric ulcer.
Diagnosis by Roentgen Ray, Carmon, Surgical and
Non-Surgical Aspects; Eusterman and C. H. Alayo.
Then comes one of the W. J. Alayo’s philosophic
discussions; “Co-ordination of the Functions of the
Gastro-Intestinal Tract.” F. C. Alann removes the
liver in dogs as a means of studying the physiology
of the organ. AlacCarthy, Jackson and Alann pre-
sent some studies on Cholecystitis and C. H. Alayo
on Cholecystectomy with Alodified Drainage and ar-
rives at the conclusion that diseased gall-bladders
should be treated by cholecystectomy. Dr. R. D.
Carman presents a beautifully illustrated paper on
Roentgenology of Tuberculous Enterocolitus. An
important paper is by C. H. Alayo under the title
Enterostomy, an Operation of Expediency and Ne-
cessity.
The second section considers Urogenital Organs
and under this head are thirteen papers. Two may
168
Journal of Iowa State ^Iedical Society
[April, 1922
be specially mentioned, one bj' Braasch and Kendall.
Investigation of the Phenolsulphonephthalem Test,
and one by Braasch, Roentgen Examination of the
Lrinary Tract made Opaque. The interest attached
to these papers lies in their value in diagnosis. Two
important papers in this section relate to the pros-
tate. Dr. Bowing presents a paper on Radium and
X-ray treatment of inoperable carcinoma of the
cervix and arrives at the following conclusion.
First Good results have been obtained in cases
of early cancer of the uterine cervix by treatment
with radium rays.
Second — The procedure of choice in the treatment
of inoperable cancer of the cervix is the application
of radium to the primary growth.
Third — Deep x-ray therapy will control metastatic
growths.
Fourth — Patients with markedly advanced cancer
should receive only limited amounts of well screened
radium rays, sufficient to control the foul sangineous
discharge and hemorrhage.
Fifth — Patients with extensive cancer of the
uterine cervix can be restored by this treatment to
their activities for a variable number of years.
Under the head of ductless glands are eleven pa-
pers. The papers present a rather full account of
the present status of the physiology, pathology and
treatment of these most important glands, which ex-
ercise such vital influence upon the body, 122 pages
are given to this subject.
The section relating to the heart and blood include
fourteen papers and present important studies which
will appeal to the internist; one of particular in-
terest to the examiners of life insurance, is by Dr.
Giffin, under the title of the Relationship of the
Anemias to Life Insurance.
There are ten papers on the Skin and Syphilis. An
important paper on Epidemic Infections, Jaundice
and its Relation to the Therapy of Syphilis, is by
Dr. Stokes, Ruedemann, Jr., and W. S. Lemon and
presents many important facts.
A long list of papers appear in the section Head
Trunk and Extremities, thirty-eight in number. An
exhaustive study in Influenza and Pneumonia is
prepared by Dr. E. C. Rosenow. This communica-
tion is of the highest importance to the medical pro-
fession. So much of vital importance is presented
that it is quite beyond the limits of this review to
do more than call attention to a study which should
be read by progressive physicians.
Dr. W. S. Lemon presents a study of a series of
eight3'-one consecutive cases of Pulmonary Abscess.
Bonj’ tumors of the chest wall are not of common
occurrence and the paper of C. A. Hedblom on this
subject will be of unusual interest.
There are many other papers of interest we must
pass over. The final paper relates to surgerj", hos-
pitals and men in South America bj' W. J. Mayo, and
will be of much interest. Hitherto our thought in
relation to medicine bej'ond our own country turn to
Europe. Dr. Mayo’s vast experience in relation to
men and things, particular!}- medical, render his
views of much value, and a contribution of this kind
is opportune, at this time, when we are trying to see
beyond our own borders.
MEDICAL ELECTRICITY ROENTGEN RAYS
AND RADIUM
With a Practical Chapter on Photother-
apy. By Sinclair Tousey, A.M., ^I.D., Con-
sulting Surgeon to St. Bartholomew’s Clinic,
New \ ork City, Third Edition. Thoroughly
Revised and Greatly Enlarged. Containing
Eight Hundred Sixty-one Practical Illustra-
tions, Sixteen in Color. W. B. Saunders
Company, 1921. Cloth, $7.50 Net.
This book will be found a very valuable reference
for the roentgenologist as well as the general prac-
titioner. The author has discussed in general the
various phases of electricity, x-ray and radium. This
edition is a valuable reference covering the general
principles of the various forms of electricity . and
electrotherapy. The technique of radiography, local-
ization of foreign bodies and fluoroscopy is generally
discussed. Forty pages of this edition has been de-
voted to radium in which is discussed radioactivity.
Bundy Allen, M.D.
NEW AND NON-OFFICIAL REMEDIES
During February the following articles have been
accepted by the Council on Pharmacy and Chemistry
for inclusion in New and Non-official Remedies:
Persson Laboratories:
Bacillus Coli Antigen (No. 50) — Persson.
Furunculosis Vaccine Mixed (No. 37) — Persson.
Gonococcus Antigen (No. 47) — Persson.
Staphylococcus Aureus Antigen (No. 49) — Pers-
son.
Streptococcus Antigen (No. 48) — Persson.
Pneumonia Vaccine (No. 36) — Persson.
Powers-Weightman-Rosengarten Co.:
Novarsenobenzol — Billon.
G. H. Sherman:
Whooping Cough Vaccine — Sherman.
Mixed Typhoid Vaccine — Sherman.
Acne Staphylococcus Vaccine — Sherman.
Winthrop Chemical Co.:
Alypin.
During January the following articles have been
accepted by the Council on Pharmacy and Chemis-
try for inclusion in New and Non-official Remedies;
The Abbott Laboratories:
Butyn.
G. W. Carnrick Co.:
Solution Post-Pituitary.
Parke, Davis and Co.:
Pituitrin “O”.
Jl^oumal of tfjc
Hotoa ^tate j$let)ual ^cietp
VoL. XII Des Moines, Iowa, May 15, 1922 No. 5
ORATION IN SURGERY— DO WE
PROGRESS ?*
W. A. Rohlf, M.D., Waverly
Could Ambrose Pare awake in a modern oper-
ating room, he would admit his boast was vain.
The surgical leader of his time, how crude his
methods today. He never even could have
dreamed or imagined the surgical possibilities of
the present. With our great accomplishments,
we might register the same boast, which in due
time would prove vain and our egotism folly.
Anesthesia, an agent so powerful in its influence
on present surgical progress, a priceless boon to
humanity, no longer excites comment or more
than passing notice; and yet, the introduction of
anesthesia and the science of bacteriology as ele-
ments of Qur progress are so recent in discovery
as to be late memories in the minds of many of
those present here today. We speak with pride
of the safe invasion of the abdomen. Surgery-
now enters fearlessly the chest cavity, and even
the heart has been reached and repaired for trau-
matic injury. The inmost recesses of the citadel
of the brain are no longer immune from the sur-
geon’s invasion and exploration. Then, we could
boast of the skill of our specialists; the suturing
of blood-vessels, nerves and the grafting of bone ;
the delicate work on the organ of sight, the re-
construction work of the last few years and the
wonders that the principle of focal infection has
produced. Focal infection has given an impetus
and a new awakening in medical and surgical
thought. The studies and observations of those
who have given this subject so much time and
unstinted effort and work, have given to us tan-
gible reports for consideration that have opened
new fields, new understandings, and have ad-
vanced the indications for surgery to a more
scientific basis.
We cannot here mention all of the incidents of
progress and such was not the intention of this
brief discourse. Proud as we may be of the sur-
gical accomplishments of the age, I would have
•Presented before the Seventieth Annual Session, Iowa State
Medical Society, Des Moines, Iowa, May 11, 12, 13, 1921.
you pause and notice from another point of view
the surgical work as a whole, relating to the whole
profession and the manner of its practice in gen-
eral. Have the end results, the practical results,
been for real progress and has the sum total of
all surgery been for the good of humanity at
large ?
The matter of focal infection and its teaching
has led to extravagance in the dental field, to the
ruthless sacrifice of healthy, desirable teeth. It
has led to the promiscuous removal of tonsils,
diseased and otherwise, with the resultant scar
tissue, lost uvulas, desecrated, mutilated pillars,
adhesions, left in the wake of needless, reckless,
so-called tonsil surgery. Is this really progress?
Considering the operations for appendicitis, for
a moment, from all angles ; the needless opera-
tions from improper diagnosis; the postoperative
distress from adhesions, hernias, even intestinal
obstruction, emboli ; the mental distress because
of failure to get relief ; the refusal of some for
operations later, for real indications, and even
the occasional death, is it progress? We have no
real statistics to answer this question. None of
us doubt that many operations have been done
without real indications, for motives surely not
for the progress forward of the science of sur-
gery. We are safe in suggesting that Cesarean
section, for example, has been done many times
for the benefit, not primarily of the woman and
unborn babe. When we contemplate that there
still exists the opportunity for women to escape
the responsibility of motherhood, that criminal
abortions still are done, mutilating operations
performed to prevent conception, and these by
men, who, in the past at least have not lost caste,
may we not question that as a whole we are pro-
gressing forward?
However, the spirit of progress is in the air
and the light of real advancement is beginning to
dawn. The awakening of the indifferent attitude
of the people is at hand and the one great influ-
ence, the one great factor that is shedding its
purifying light into the dark recesses of the pro-
fession of surgery, that is beginning to clarify
the situation and is making for true progress, is
170
Journal of Iowa State Medical Society
[May, 1922
the work of hospital standardization. Results
are even now manifest, as the fruit of the efforts
of those actually engaged in pushing this great
educational movement and the hearty cooperation
of the hospitals themselves and the support of
the medical profession. We may, I think, point
out with assurance, with hope and with pride,
that this one institution is making for real prog-
ress. It is so self-evident that the system of
record keeping, the actual taking of careful his-
tories and the routine laboratory work will fre-
quently prevent errors, even by those who have
in the past actually tried to do their best work
without this routine system, or act as a check on
hasty conclusions leading to needless operations.
Again, the men grouped together in any hospital
are individually benefited in many ways. It leads
to better understanding, mutual helpfulness, the
frank open discussion, the summary cards open
to the staff for study and constructive criticism,
will surely assist in stimulating for better effort
and eliminating the work that is questionable in
character.
And surely as important as this hospital stand-
ardization is to the medical profession, is the
education of the laity, who are beginning to ap-
preciate the real value of conscientious, scientific
and well founded diagnoses. The laity is de-
manding a diagnosis first, instead of remedies. It
seems that the general scheme of hospital stand-
ardization is worthy of the best support of all
fair minded practitioners.
Another matter I wish to mention, and it is
only in a meeting of medical men that I would
think of discussing this subject, at least I would
ignore it in my relations with the laity, and these
remarks are actuated by reading the following
in a weekly newspaper. This article has been
widely disseminated by the newspapers of our
state :
Chiropractics Win Long Fight for Recognition
Des iloines, February 26: The twenty-six year
fight of chiropractics for recognition in Iowa ended
today. With publication of the bill just passed by
the legislature, the law legalizing the practice of
chiropractic and giving practitioners the same rights
and privileges as physicians and surgeons went into
effect today. Since the discovery of the art of spinal
adjustment by D. D. Palmer of Davenport, Iowa, in
1895, its practice has been bitterly fought by physi-
cians and surgeons.
The fact that this sort of bill, which puts on an
equal footing with physicians and surgeons the
exponents of this fad, fancy and foolishness, il-
lustrates that as politicians the medical fraternity
is a failure. Perhaps it is indifference — it should
not be, when we consider that the state insists on
seven years hard work for medical and surgical
men before granting permission to practice, when
our great state spends money to keep up the State
University of Iowa, insists on examination by the
state board before recognizing their right to prac-
tice, and then extends the same courtesy to a
class that practically has no training without this
same examination, we might question very seri-
ously progress. Can we not insist on the abolish-
ment of class legislation and have one standard of
examination for all who aspire to treat and heal
the sick? Can we not progress, politically at
least, to the extent that our legislatures be made
to cease spitting in the face of the very constitu-
tion of the United States by enacting laws that
are absolutely class legislation ?
As representing the rural community, I take
the opportunity to mention the question of pres-
ent day nursing service as it relates to rural sur-
gery. The primary motive of this profession was
that of service, at least the spirit of service per-
meated the founders of this great work so in-
timately correlated with the practice of medicine
and surgery. Our recent experience is leading us,
though unwillingly, to believe that some members
of the nursing profession are becoming more or
less commercialized. What the remedy is may be
a question. That the service of trained nurses
is sorely needed there is no doubt, also that the
supply is inadequate. Is the entrance standard
too high ? Experience has shown us that some of
our best nurses have come from the ranks of
those who have in early life been denied the
privilege of a high school education. We can
not take time to discuss this nursing proposition
at length, but I wish to make the statement that
I believe a two year course, properly given, with
better pay while in training, would help to relieve
the really serious condition, that of the shortage
of nursing service for real need in the rural com-
munity. The opportunity for special training for
those who aspire to higher positions in the nurs-
ing service should, could and would be given to
supply nurses for the work that relates to teach-
ing, such as hospital superintendents, dieticians,
school nurses, social welfare nurses, special sur-
gical nurses, etc. It would be a real boon to the
ordinary surgeon and practitioner of the rural
community, as well as to people of only ordinary
means to be able to secure nursing service from
those who have taken only two years training.
This would,' at least in a measure, overcome the
increasing demand and the decreasing supply of
nursing service as well as the overcharging which
now deprives many people of any sort of nursing
A"ol. XII, No. 5]
Journal of Iowa State Medical Society
171
service and would eradicate some of the excuses
for failure to answer calls, no matter how great
the need.
I take this opportunity to say that alumnae of
the State University of Iowa, who attended the
recent clinic there, are unanimous in the declara-
tion that the manner of present day teaching is
certainly a sign that the science of medicine and
surgery is progressing. We were especially im-
pressed with the spirit of devotion, the spirit of
service to the highest ideals of medical and sur-
gical science. We are proud of our State Uni-
versity Medical School and I am sure that as the
alumnae of other schools attend the clinics and
demonstrations of present day methods of teach-
ing that the great examples of progress and devo-
tion are not confined to the State University of
Iowa. Unquestionably much of the progress and
advancement in the science of medicine and the
spirit of devotion, self-sacrifice and the con-
scientious research and investigation is by the
teachers and their assistants in these medical
centers. They are all worthy of the support of a
loyal, enthusiastic and wideawake alumnae.
Within the memor}' of most of you present,
our great State of Iowa was here and there dotted
with swamps and foul morasses, overgrown with
rank, poisonous weeds. Swamps, on whose slimy
bottoms there crawled cold, hideous reptiles ; and
there the wild waterfowl came yearly to raise
their broods. Civilization advanced, systems of
drainage were instituted and the light of heaven
continued to shine upon this veritable garden;
and now in place of these swamps we find waving
fields of golden grain, and where the poisonous
reptiles crawled, now the bare feet of children
patter amidst beautiful, perfumed flowers.
The light of scientific medicine for centuries
has been shining into morasses where lurked ig-
norance, superstition ; and upon the slimy ooze of
the bottom there lurked that lowest form of
human society, the commercialized quack. But
the light of scientific medicine is still shining and
we can begin to see the dark veil of ignorance lift-
ing. Ignorance is giving way to knowledge,
vague superstition to understanding, and even the
quack, as he moves about in the slimy ooze of
this foul morass is finding the watery cloak of
immunity being slowly evaporated and beginning
to reach the security of his erstwhile protected
position. He is no longer quite so safe in preying
upon the agony of mother love as she contem-
plates the suffering of her offspring afflicted
with a painful, incurable malady. He is getting
more and more uneasy as he filches the bank
account of the hopeless paralytic, the hopeful.
doomed, though optimistic, victim of late tuber-
culosis. The time is coming when the concentra-
tion of the light of progress will drive him from
his nefarious trade and practices. With a spirit
of unselfish service and devotion, of scientific
investigation and tireless energy as exemplified
in the great results from the efforts of Pasteur,
Koch and Lister, as advanced later by such men
as J. Marion Sims, Moses Gunn, Bigelow, IMor-
ton and many others whose names come to our
minds, including those of our own state — the able,
progressive Peck, the smooth, scientific Middle-
ton, Nicholas Senn, Christian Fenger — and the
multitude of others, contemporaneous with these.
Stimulated and inspired by such great teachers,
devoting their energies with this spirit of true
scientific investigation, actuated by a true spirit
of service to humanity, are our present day teach-
ers, the Rosenows, IMurphys, Criles, Deavers,
Mayos, Finneys, Frasiers, and our own beloved
Donald McCrae.
We have no fear of the future. We are proud
of the accomplishments of the present, and in the
face of all the failures and shortcomings of the
past, with such questions as that of cancer still
unanswered, we are all optimistic enough to be-
lieve that our surgical profession, from all points
of view, from scientific achievement to the spirit
of service to suffering humanity, is such that
we may with faith and confidence declare, “We
do progress.”
THE RELATION THAT EXISTS BE-
TWEEN HYPERTENSION, MYO-
CARDITIS AND NEPHRITIS*
Henry A. Christian, M.D., Boston
Analysis and synthesis are methods by which
we seek to obtain knowledge of unknown sub-
stances, processes and conditions. In internal
medicine we use analysis to subdivide and classify
cases representing a general group and so try lo
obtain a more complete knowledge of the condi-
tion. As an example, we subdivide pulmonary
tuberculosis into miliary tuberculosis, tubercu-
lous pneumonia, tuberculosis with cavity forma-
tion, etc., and recognize that these different va-
rieties have a different prognosis, should receive
different therapeutic management, have different
physical signs, etc. In such a method of study
we emphasize differences and use differences as
a basis of classification or grouping. By con-
trast in synthesis we dwell on similarities and by
•presented at the Milwaukee Session. Tri-State Medical Associa-
tion, Iowa, Illinois and Michigan.
172
Journal of Iowa State Medical Society
[^Iay, 1922
using sinjilarities we bring together smaller
groups into larger groups. To return to tubercu-
losis, we recognize that all forms have a common
etiology, the tubercle bacillus, that the anatomical
differences depend on the number of tubercle
bacilli and how they make their entrance, on the
tissue infected and the degree of resistance in the
patient, that we are dealing with a single disease,
tuberculosis, which in its relation to the general
public is much the same whatever the type in the
individual.
Both analysis and synthesis contribute to our
advance in knowledge of disease. The method
of analysis perhaps is more often used in medi-
cine and as a result we discuss classifications of
all sorts of diseases and conditions. By so doing
we learn much, but on the whole we increase the
complexity of medicine and sometimes we do this
without ad\ancing greatly our actual knowledge
of the subject. On the other hand synthesis,
when it is possible, tends to simplify our con-
ceptions. Both processes undoubtedly need to
be used in studying disease, analysis with its sub-
dividing up to a certain point, then synthesis,
putting together our knowledge into broader con-
cepts.
Today I am going to discuss that group of pa-
tients who, broadly, we- term cardio-renal from
the viewpoint of synthesis, dwelling on similari-
ties rather than differences, attempting to see
what common ground there may be in patients
who present themselves as suffering in the main
from hypertension or from myocarditis or from
nephritis. In doing this one naturally considers
what relations there may exist between hyperten-
sion, myocarditis and nephritis.
The motto of your society is an equilateral tri-
angle with the name of one of the states on each
side of this triangle. Without knowing its real
origin I assume that this motto means the union
of the medical strengths or interests of these
states, each state being of equal importance in
the organization, but each dependent on or bound
to the other two so as to gain strength and
solidarity by the union. To express a somewhat
similar relationship I will use your triangle and
instead of Iowa, Illinois and Wisconsin, I will
substitute hypertension, myocarditis and neph-
ritis. This arrangement indicates that these terms
have an individual independence like states but
also an interdependence through which this triad
forms an important expression of the general re-
lationships of significant morbid processes in the
human economy. It is chiefly about this latter
aspect, interdependence, that I will speak.
If you will pass over in your mind recent pa-
tients in whom you have made the diagnosis hy-
pertension, or myocarditis, or nephritis and recall
the findings in different ones of them, you will
recognize that sometimes there were abnormali-
ties which seemed to justify the diagnosis of but
one of this triad, at other times two or even three
of them. That is, there were some cases in which
you could demonstrate but a high blood-pressure
without exidence of cardiac or renal damage,
while there were other cases in which, without
a high blood-pressure or abnormal renal lesion,
the heart was enlarged and improperly func-
tioned. In yet another group there were normal
blood-pressure and a properly functioning heart
muscle, but poor renal function. iNIuch more
commonly the findings indicative of one of these
groups were combined with those of another or
there was a combination of all three. Then, if
you will think of the progression of events in any
one of these cases, you will recall that in some
at first there was hypertension, but later the heart
enlarged, that somewhat later poor renal function
appeared and, finally, a decompensated heart was
combined with a picture of uremia. In other
cases a combination of two but not of all three
conditions appeared. The occurrence of these
combinations suggests a close interdependence of
these processes in their cause and their progres-
sion.
Let us first consider hypertension. The pre-
vailing view at present is that hypertension is de-
jiendent upon changes in the small arteries, the
arterioles, scattered throughout the body and that,
while it is often combined with the condition in
the larger arteries, which we term arteriosclerosis,
it is not caused by such arteriosclerosis. Without
question we find hypertension in patients in whom
there is no demonstrable arteriosclerosis and ar-
teriosclerosis of marked degree occurs with nor-
mal blood-pressure. Sir Clifford Allbutt early
recognized this independence and considered ar-
teriosclerosis a degenerative or decrescent pro-
cess quite apart from hypertension, or, as he
called it, hyperpiesis. It is well to bear in mind
that, in a clinical sense, arteriosclerosis is usually
used as a term to indicate that the larger arteries
show thickening of their walls, tortuosity and cal-
cification in varying combinations and that hyper-
tension or hyperpiesis means a persisting high
blood-pressure. It is incorrect to infer that, be-
cause there is arteriosclerosis in this clinical
sense, the blood-pressure is high, and equally in-
correct to think that hypertension is not present
because the palpating finger detects no changes in
the arterial wall. As a matter of fact, very often
arteriosclerosis in this clinical sense and hyper-
\’oL. XII, No. 5]
Journal of Iowa State IMedical Society
173
tension coexist but the former does not cause the
latter. Very often these mistakes are made in
discussing patients with arterial disease.
Granting that the immediate cause of hyper-
tension lies in the arterioles, i. e., is due to an in-
creased peripheral resistance from narrowing of
the peripheral vascular bed at the level of the
arterioles, what changes, if any, will be found in
the arteriole? Either spasm of the vessel wall or
an organic change in the wall causing a narrow-
ing of the lumen or interfering with the dilata-
tion of the vessel will result in an increased blood-
pressure if these changes are very general in the
body. If there is spasm alone the microscope will
reveal no change in the body tissues. If there is
an organic lesion, the microscope will show thick-
ening and degeneration of the wall of the ar-
terioles. It is believed that in earlier stages of
the process often there is only spasm while later
there are organic changes; what you find under
the microscope depends on this.
What is the cause of these changes in the
arterioles? By many it is stated that nephritis is
the cause of hypertension and that consequently
finding a high blood-pressure justifies the diag-
nosis of nephritis even though there is no other
evidence of renal disturbance. We now know
that very often we find hypertension in patients
in whom renal function, tested by any method, is
practically normal and that in hypertensive cases
autopsy in some instances shows only minimal
lesions in the kidney. In other words, we have
evidence that nephritis is not a constant cause of
hypertension. Whether nephritis ever causes hy-
pertension will be discussed later.
Another cause for hypertension, rather recently
adduced, is that it results from a disturbed salt
metabolism and can be satisfactorily treated by
eliminating salt from the diet. Our studies at the
Peter Bent Brigham Hospital have not supported
this view. This is not to say that in some cases
of hypertension we do not find poor salt elimina-
tion. This has been long recognized, but it is our
belief, based on our own observations, that salt
retention is dependent on a disturbed renal func-
tion and an accompaniment of some cases of hy-
pertension rather than an important causative
factor.
Infection has been adduced as an important
cause of hypertension in the sense that it has
lead to the vascular lesions. Antecedent infection
rather than coincident infection is what is de-
scribed. Hence it is not likely that infection
would cause spasm but rather organic lesion of
the wall of the arterioles. Evidence for this is, in
the main, statistical and is subject to considerable
error; it is easy to find a history of infection ot
some sort in most adults ; whether there are more
infections or infections of a more severe or more
chronic type in cases of hypertension is difficult
to decide for any large group of cases. We do
know that many infections cause vascular lesions
demonstrable under the microscope and these
very probably may lead to persisting vascular
changes causing hypertension. Anyhow, there is
a growing belief that infection plays a large part
in causing hypertension. Curiously enough, how-
ever, syphilis which we know to produce some
striking vascular lesions, such as aortitis and
aneurysm and in whose lesions of all sorts peri-
arteritis is prominent, seems to play but a small
part in hypertension ; the proportion of patients
with hypertension who have positive Wassermann
reactions is relatively very small and antisyph-
ilitic treatment rarely benefits hypertension.
Some endocrine disturbances are associated
with hypertension, but that such a cause is at all
general seems very improbable. I might discuss
other assigned causes in a similar way. What I
want to emphasize, however, is that today we
know of no one final cause of hypertension ; a
number of factors play a part and perhaps there
are a variety of causes. Hypertension very likely
is, in a sense, of the nature of a sympton and not
a disease, an expression of a disturbance that,
like fever, might have many causes. As to the
mechanism, it seems pretty certain that it is
caused by a disturbance in the small blood-vessels,
arterioles and smaller, of the body.
X"ow let us turn to nephritis and consider it
somewhat as we have hypertension. For neph-
ritis we have better knowledge of the organic
lesion than we have for hypertension for we
find in practically every case some demonstra-
ble lesion in the kidney. However, as in hy-
pertension, the degree of functional disturbance
often is quite out of proportion to the demonstra-
ble organic lesion. Again, in nephritis the rela-
tive relation of vascular to epithelial lesion is not
fully understood. There is a considerable body
of evidence that, in a large, group of nephritides,
the vascular lesion is the primary and the most
important disturbance, while the changes in the
epithelial structures are secondary to the vascular
lesions. This applies particularly to that large
group of renal patients that we ordinarily speak
of as having chronic interstitial nephritis. More-
over, there is a growing feeling that the eye
changes, commonly spoken of as albuminuric
retinitis, are in essential vascular lesions of local
origin, bearing only an indirect relation to the
renal lesion and having no relation to uremia. If
174
Journal of Iowa State IMedical Society
[:\Iay, 1922
this is true, not only is this type of nephritis in
large part a vascular lesion, but also it is one ex-
pression of a general process involving other
vascular territories than those within the kidney.
I have already spoken of the possible relation-
ship between hypertension and nephritis and
stated that nephritis does not bear a constant
causal relation to hypertension but that hyperten-
sion may be found without evidence of nephritis.
Certain types of nephritis are not accompanied
by high blood-pressure, while with other types we
have hypertension. In some cases we have re-
corded observations of hypertension prior to evi-
dences of nephritis and later see the picture of
nephritis develop. In other cases we have no
positive evidence of hypertension prior to the
development of symptoms and signs of nephritis
and in certain of our cases of acute nephritis we
observe the blood-pressure to rise as the nephritis
progresses. So I am inclined to think that at
times high blood-pressure is caused by nephritis,
but it is not possible to say how often this is true
in chronic nephritis, and we do not know just
how the hypertension is brought about. It is
also true that the vascular lesions causing hyper-
tension may in the kidney cause the clinical pic-
ture of nephritis, perhaps indirectly actually
cause nephritis.
Disturbed salt metabolism is often present in
nephritis, but that it is a direct cause does not
seem very probable. On the other hand, almost
all students of the renal problem believe that in-
fection is a very important causative factor in
nephritis. Here, as with hypertension, direct evi-
dence is often lacking, but the frequent observa-
tion of an infection just prior to the development
of an acute nephritis is very suggestive so far as
acute nephritis is concerned. With nephritis, as
with hypertension, syphilis appears to play only
a ver}- minor role.
It is recognized that certain of the endocrine
disturbances effect renal function but there is
little evidence that any such disturbances cause
nephritis. You see, as with hypertension, nepn-
ritis perhaps has a variety of causes not all of
which, by any means, have I attempted to discuss.
What I wish to emphasize is that there is observa-
tional evidence that in some patients hyperten-
sion bears some, even though an indirect, causal
relation to nephritis and that both in hypertension
and in some types of nephritis a lesion of small
blood-vessels is an important part of the causa-
tive mechanism of the processes.
If now we treat myocarditis from the same
viewpoint, we find much in common with the
conditions which I have just discussed for hyper-
tension and nephritis. Perhaps it is necessary at
this juncture to define my use of the term myo-
carditis. I mean by myocarditis a disturbance in
the heart muscle, which leads to cardiac insuffi-
ciency, a type of heart which is usually enlarged
but in which the valves are structurally normal.
There is no constant finding as to type of irreg-
ularity, though sooner or later in the majority
auricular fibrillation develops ; however, some
cases never develop arrythmia. Under the mi-
croscope the heart muscle may appear surpris-
ingly normal and changes in the interstitial tissue
may be very slight or even absent.
For the cases of myocarditis I think we know
less in regard to the lesion than we do for either
hypertension or nephritis, certainly far less than
for nephritis. That the disturbance in the heart
muscle is primarily referable to the small arteries
is an attractive hypothesis, fitting many of the
associated phenomena but of which unfortunately
we have little positive evidence. Coronary sclero-
sis is often present but is very far from a constant
finding.
The association of chronic myocarditis with
hypertension is interesting. Very often we have
the opportunity to observe a patient with a high
blood-pressure whose heart so far as we can
judge functions normally and we cannot demon-
strate any real enlargement. A little later in the
same patient we find the heart enlarged. Still
later there is breathlessness and finally cardiac
decompensation with all of the findings that lead
us to make the diagnosis of chronic myocarditis.
High blood-pressure has persisted throughout.
What is its relationship to the myocarditis? It
is simple to say continued work against abnormal
pressure has lead to the cardiac disturbance, but
is it so ? IMost observers are rather unwilling to
say that a true work hypertrophy with subsequent
decompensation of the heart can occur. It seems
more probable that some common cause has lead
to hypertension and to the cardiac lesion and that
cardiac enlargement is but a phase in the progres-
sion of the lesion.
In contrast to such a patient we see patients
with identical cardiac findings but with normal
blood-pressure. Some observers intimate that
here hypertension has antedated cardiac decom-
pensation and cardiac decompensation, at the
time the patient is first observed, has caused a
previously high pressure to fall to normal. It
seems to me that the evidence for such a belief
is insufficient and that such a sequence is more
improbable than probable. To my way of think-
ing just the same cardiac lesion may develop
either with or without hypertension. However,
VoL. XII, No. 5]
Journal of Iowa State Medical Society
175
this is not to deny that there may not be a vascular
lesion at the bottom of each type of myocardial
lesion ; to have hypertension the vascular lesion
must be quite general and not merely localized
in one or several organs. We can sav that, if it
is general, we have hypertension; if it is localized
in the heart, we have chronic myocarditis; if it is
both general and localized in the heart we have
hypertension and chronic myocarditis.
The role of infection in causing myocarditis
stands as unproven. There is considerable evi-
dence in its favor but relatively little direct proof.
Still we do observe a typical chronic myocarditis
develop as a sequence of such an acute infection
as pneumonia often enough to give support to the
view that infection plays an important role. On
an inferential basis, as for nephritis and hyper-
tension, we are justified in the hypothesis that in-
fection may be an important factor in causing
changes in the heart muscle that result in that
form of cardiac insufficiency which we term
chronic myocarditis. As for hypertension and
nephritis, syphilis seems to play a minor role ; as
in the other two conditions our findings at the
Peter Bent Brigham Hospital of positive Was-
sermann reactions or other evidence of syphilis in
these cases of chronic myocarditis are infrequent.
As to endocrine disturbances, we know that a
continued hyperthyroidism often leads to a car-
diac disturbance of the nature of chronic myo-
carditis ; yet it seems improbable to me that it is
the cause of any large proportion of cases of
chronic myocarditis. Certainly in Boston we fail
to find evidences of antecedent or coincident hy-
perthyroidism in these cases and similarly evi-
dence of other endocrine disturbances are very
infrequent.
I have attempted to show that, so far as we
know, very similar causative factors are operative
in the production of hypertension, nephritis and
myocarditis even though we can but rarely say
for a given case that the cause has been a definite
one. Furthermore, we have either direct evi-
dence, good inferential reasons or well supported
hypothesis, for believing that in all three condi-
tions disturbance in the small arteries constitute
an important part of the lesion. All three condi-
tions occur with far greatest frequency at middle
life or later, though all may be observed occa-
sionally in the young.
The similarities which I have brought out jus-
tify us in grouping hypertension, nephritis and
myocarditis together. We are not justified in
claiming that there is any constant sequence in
these processes or that in any given case at any
period of time all three will be present. In fact.
we have to recognize that we see patients with
nephritis without hypertension and without myo-
carditis and myocarditis cases without hyperten-
sion and with only such renal disturbance as is the
result of chronic passive congestion. These find-
ings, however, do not preclude a common lesion
with different manifestations dependent on what
viscera are extensively involved. Also, they do
not prove that in all three the same general pro-
cesses, namely, vascular disturbances, are oper-
ative. I think we can state that, if a hypertension
develops and persists, sooner or later we will be
able to demonstrate changes in the larger vessels,
i-. e., arteriosclerosis in a clinical sense, that the
heart will hypertrophy and become insufficient,
i. e., chronic myocarditis will ensue and that renal
insufficiency will appear, i. e., chronic nephritis
will develop. In some cases this actual sequence
will take place; in other cases the sequence will
be different but the end stage the same. Finally,
the progression may be stopped by death at al-
most any stage and so the end result in any given
case may be hypertension with arteriosclerosis
and little else or with these there may be chronic
myocarditis but no real nephritis or chronic neph-
ritis without any actual cardiac insufficiency. In
a pathological sense there may be lesions very
marked in arteries, heart and kidneys or much
more marked in one than in the others.
I believe that there is much evidence for a
very close relationship between what we clinically
term hypertension, myocarditis and nephritis and
that a better understanding of these processes is
obtained by considering their resemblances rather
than their differences whether we are studying
their causes, their manifestations or their man-
agement. In other words, synthesis is more help-
ful at the present stage of our knowledge than
analysis in considering hypertension, nephritis
and myocarditis.
LUMINAL IN THE TREATMENT OF
EPILEPSY: PRELIMINARY REPORT*
M. Nelson Voldeng, jM.D., Woodward
First of all I think I owe you an apology for
appearing before you at all at this time. Aly
reason for not preparing a set paper is the fact
that our experience with this new remedy is of
too recent origin to warrant us in coming to any
definite conclusions, and we want to avoid state-
ments which might lead any of you to believe
that the results have been other than what the\
really are.
*Presented before the Seventieth Annual Session. Iowa Sta^c
Medical Society, Des Moines, Iowa, May 11, 12, 13, 1021.
176
Journal of Iowa State Medical Society
[May, 1922
To begin with we want it understood that any
remedy that will cut short or reduce or eliminate
convulsions, does not necessarily mean or should
not lead anyone to the belief that the disease has
been cured. Howe\ er, the convulsion is a symp-
tom, it is the most prominent symptom, and any
patient who is suffering from the disease will be
\ery grateful indeed pi'ovided you can eliminate
the seizures, or even improve that particular con-
dition.
Xow, what I am a little afraid of as a resuU
of the promiscuous use of luminal in the treat-
ment of epilepsy, is this : That we will get into
the habit of using the drug indiscriminately, a<
has been the case with bromids more particularly.
Luminal should be administered with a great deal
of care and only by persons who are willing to
keep air accurate observation of the action of the
drug, and the physician should be anxious that
the patient reports to his office at regular and
stated intervals. As it is now, a few physicians
procure a large quantity of the drug for the pa-
tient and send him away rejoicing. Also in many
cases the dose given is too large, to begin with at
least. So I feel that we should be e.xtremely cau-
tious in the use of the drug, and maintain strict
observation of the patient.
So far as dosage is concerned, it should be your
object to give only sufficiently large dose to con-
trol the seizures. Ordinarily, it has been our ex-
perience that Ijd grain once a day will do this.
If you are dealing with a case that has been tak-
ing large doses of the bromids, it is a little dan-
gerous to withdraw the bromid abruptly. You
should either withdraw the bromid slowly, or
give an additional dose of the luminal, say one-
half grain, in the moming, and the grain and
one-half in the evening.
During the past thirty-five years I have used
almost everything that has been recommended for
epilepsy or the control of the seizures, and I
want to say that in our experience luminal has
done infinitely more than anything we have ever
tried. But do not go away from here with the
idea that we are curing epilepsy. In the first
place I do not believe that we have used it long
enough to warrant us in making any definite
statements. We started the regular use of this
drug last November. We have been using it con-
sistently and regularly in 114 cases. During this
time there have been three unavoidable inter-
ruptions lasting from a week to two weeks when
we were unable to procure the drug.
The physical properties of the drug you prob-
ably are familiar with. It comes in grain
tablets, or you can secure it in powder form. It
is colorless, slightl}' bitter, almost completely or
totally insoluble in cold water, slightly soluble in
warm water and in an alkaline solution ; freely
soluble in ether, alcohol, and chloroform.
Some observers have preferred the administra-
tion of this drug in hy podermic form, and if you
conclude to give the drug that way you should
procure the sodium luminal. This is freely solu-
ble in water and should be made up in a 20 per
cent solution, and from that solution the dose
should be 3 grains — twice that of luminal. But
only one hypodermic iniection a day should be
given unless you find that the seizures are not
properly controlled and that you do not have the
effects you think you ought to have, when you
can give one-half of this dose in the morning.
Luminal was first used in 1912 by several Ger-
man physicians for the purpose of replacing-
veronal. As a hypnotic it acts veiw much more
efficiently than veronal. It was first used among
the insane, especially in the disturbed and excited
states. It quiets the disturbed case much better
than anything we have tried. Dr. Dercum re-
ports a remarkable cure in a very severe case of
chorea accompanied by insanity, and those of
you who have had experience with chorea of this
nature will appreciate what it means to have
something that appears to be efficient in the
treatment of these cases. After the first injec-
tion of 3 grain of luminal sodium in this case.
Dr. Dercum states that the movements subsided
materially, the patient obtained some sleep, ami
after four injections four hours apart the patient
was practically in a normal state.
Personally I ha\e had some experience with
the use of luminal in aggravated cases of neu-
rasthenia. I now have in mind the case of a
man of middle age who suffered from a very
severe attack of what we ordinarily would term
neurasthenia. After two months’ treatment with
luminal, nothing else, this patient tells me, and
his appearance wouM indicate that he is telling
the truth, that he is in better condition than he
has been in fifteen years. He claims that he had
suffered from neurasthenia for that length of
time. So I feel that in this condition also luminal
has a place.
Dr. Grinker of Chicago, in 1916, gave the first
discussion on the treatment of epilepsy by luminal
in this country. Dr. Dercum began using it in
the disturbed and excited states one year later.
He did not, however, use it in epilepsy until 1919.
The first improvement noticed is a decrease in
the number of seizures. There is a definite
change in the nature of the seizures, the convul-
sions being much milder and of shorter duration.
\'0L. XII, No. 5]
Journal of Iowa State Medical Society
177
There is also a marked impro.vement in the dispo-
sition of the individual. Those who are familiar
with the ei)ile])tic state realize that there are per-
haps no ])atients with whom we come in contact
more obstreperous, more quarrelsome, and more
fault-finding and difficult to manage, than the
epileptic. W'e have noticed a marked change in
this respect. \\ e have also noted a marked
change in the number of injuries received during
seizures.
Respiration, circulation, and temperature ap-
pear to be uninfluenced by the administration of
luminal.
As yet no one has attempted to make any state-
ment as to how this drug acts. But we know
from actual experience that it favorably affects
the epileptic and some other nervous conditions,
and in this connection I want to cite an extra-
mural case. A little over a year ago, before we
were able to get the drug in sufficient quantity to
use it regularly among our own people, a boy
fourteen years of age was brought to us from the
northwestern part of the state. This boy had had
epilepsy since he was seven years old. At the
time I saw him the seizures were averaging one
a day. Some days he would have two or three,
then he would go two or three days without hav-
ing an}’. All I prescribed for this boy was three-
quarters of a grain of luminal given at 5 o’clock
in the evening. For two months the patient had
an average of one convulsion a week, after
which time the seizures ceased entirely. The boy
is a junior in high school this year. Only a week
ago I had a letter from his father stating that the
boy is entirely well.
So far as the effects of luminal on the system
are concerned, I do not think there is any dange-
in giving the drug indefinitely. The drug is not
habit-forming, largely perhaps for the reason that
its administration is not accompanied by either
pleasurable or disagreeable sensations.
Discussion
Dr. Frank A. Ely, Des iloines — In attempting to
estimate the relative value of the various remedial
agents used in the treatment of epilepsy, we must
first of all take into account the freakishness of the
disease. I, too, have had an experience similar to
that of Dr. Voldeng, in that I have used almost every
measure that has been exploited as an agent with
which to combat epilepsy’, among them quite a few
cases that I have treated with snake vernom, think-
ing in one or two instances that I really had some
good results. By way of illustrating the various ten-
dencies of the disease, I recently had a man come
into the office who up to the age of eighteen had
epileptic seizures almost every day. At the age of
eighteen they abruptly ceased without any particular
treatment of any kind, and he was fifty-four year.'
old when I was permitted to see him. During all
this time there had apparently been no ill-effects
from his early condition, and no seizures had oc-
curred. Therefore, bearing this in mind, we arc
much less apt to form a false estimate of any form
of treatment. 1 could enumerate these instances at
great length. I have had rather a modest experience
with the treatment of epilepsy by means of luminal;
nevertheless I wish to say that, as far as I am able to
observe, it does what bromid will do, only in a very
much better and more effective way. With regard
to the dosage, I have had several individuals take the
dosage into their own hands, some of them have
taken as high as two 1J4 grain tablets at a time
twice a day. They spent most of their time sleeping.
In one very bad case the patient started in in that
manner, his epileptic seizures immediately ceased
and the old gentleman has been very much better
ever since. But, of course, I cut his dosage down
very materially. Now, my experience has been a
little different from that of Dr. Voldeng, in this: I
have not found that the drug does as well with the
petit mal cases as it does with the very bad ones. In
a number of instances in which the patient had beeii
having from one to three seizures a day, the admin-
istration of lyi grain at night and perhaps 1 grain
in the morning has brought about cessation of the
seizures. In one case it is now three or four months
since the individual has had an attack at all. In the
use of this agent you will be greatly disappointed in
some cases, while in others you are going to feel
that it is a marvel of therapeutic efficiency. With
Dr. Voldeng I wish to emphasize the fact that the
cessation of seizures does not constitute a cure. We
are begging the question whenever we attempt to
treat epilepsy, simply because we do not know the
real etiology of the condition. I think it is the same
thing as the grain of an oak tree; it is a physical
stigma by which the brain is rendered excessively ex-
plosive, and I believe that the value of these remedies
lies in the fact that they reduce the explosiveness of
and increase the inhibition of the cerebral cortex.
It is from this standpoint that we treat these cases.
I wish also to emphasize the point that these people
should be kept on the treatment continually, and
over a long period of time after they have ceased to
have any seizures. But above everything else, al-
though you may have a splendid remedy here, do not
forget the hygienic regimen on which the patient
should be placed. Two of the most brilliant results
I have had in the treatment of epilepsy occurred in
boys who were having attacks at about the age of
fourteen, and who were placed in an outdoor en-
vironment. In one case the father gave the boy a
flock of sheep. He remained outdoors w’ith this
flock of sheep, also he had a string of traps in the
winter and followed the traps all winter long. In
other words, we adopted in that case an outdoor,
non-exciting regimen and one which increased the
boy’s vitality and enhanced his resistance and inhi-
bition. I believe that outdoor life with moderate
178
Journal of Iowa State Medical Society
[May, 1922
physical exercise the year round is going to do the
most for these terribly afflicted individuals.
Dr. Thomas Byrnes, Woodward — Dr. Voldeng’s
long years of experience in the treatment of epilepsy
entitles his version as authoritative, and I therefore
am somewhat timid in venturing any remarks. Per-
sonally my experience with luminal is limited, but I
am of the opinion that therapy based on anything
short of etiological factors is but palliative and in-
adequate. It is not my intention to enter into de-
tailed discussion of the etiology of this condition;
suffice it to say that the brain cell functions through
the direct force of stimuli, which by its insufficiency
or by its excess maj^ entail degeneration. An excess
of stimuli may excite or repress according to its in-
dividual reaction. Marsh is of the opinion that
epilepsy is an abnormal muscular reaction to strong
mental states. It is an abnormal expression because
the muscular activity does not gain the end for
which the emotional state was generated. It is un-
natural also because it is effort undirected. The
epileptic, because of his peculiar makeup, cannot
avoid the dangers of too great stress as the normal
man meets it, but by an emotional drive which can-
not readily be checked labors on to mental exhaus-
tion in unconsciousness. This is not deep enough to
involve the motor life centers of the brain, so we
have a convulsion. To Bisgaard and Norvig do we
owe the first well defined endogenous substance yet
found in connection with a psychic seizure. In their
research upon epileptics, they found some hours pre-
vious to a seizure a remarkable increase in the am-
monia content of the urine, being equivalent to
about a 1.7 per cent solution. Taking this as an in-
dex, thej- made blood examinations and happened
upon the pressure rise. They attribute this condi-
tion to a deficiency in the parathj-roids, associating it
with chorea, tetany, and other psychoses. Thus it
would seem this is a kind of anaphylactic shock or
poisoning with albumin waste products, and while
other toxins may be associated the^' are not able to
bring on a seizure until the ammonia reaches a cer-
tain concentration in the blood. These investigators
used autotransplantation very successfully, homo-
transplantation not so, perhaps due to some differ-
ence between the donor and recipient. At this time,
through the good offices of Dr. Voldeng, I am at-
tempting research therapy along that line, with the
association and cooperation of Dr. Henry Harrower
of Glendale, California. iMy personal experience with
endocrine therapy has been marvelous, and I be-
lieve that for the epileptic there is something in
sight. This condition is endocrine in origin, and I
have seen brilliant results in this work and hope
within another year to give some positive evidence
along that line.
Dr. John F. Herrick, Ottumwa — The drug luminal
I have been acquainted with for about six or eight
years, through the report of Dr. Brill of Xew York
to whom I sent a patient for a condition other than
epilepsy. He suggested the use of luminal because
of certain convulsive manifestations, and I have been
using the drug in a few cases since, possibly twelve
to fifteen. It is presumptuous for me to discuss Dr.
Voldeng’s paper, and }'et I would judge that my use
of the drug would antedate the use of it by the ma-
jority of physicians in this part of the country. 1
will relate a few cases. A Avoman fifty-five years of
age had been an epileptic all her life, the seizures
were becoming very frequent, two or three a day,
and the mentality and disposition were beginning to
be affected, as related by Dr. Voldeng in certain
cases. I had in mind the possibility that our friend
Reed of Cincinnati might have had some truth in his
doctrine. So, in addition to luminal, I put this pa-
tient on an alkaline cathartic mineral water, giving
enough of this each morning to secure flushing of
the bowel. The result was that with grain of
luminal at night and a dose of mineral water in the
morning, inside of a month this lifelong epilepsy was
stayed and she went a year without an epileptic at-
tack. She thought then that she was well, and as she
lived at a distance from my office she took it upon
herself to drop all treatment. But after a few months
she had an attack. Since I had given her a prescrip-
tion for the luminal she secured an additional sup-
ply. However, she did not get the beneficial result
she had experienced in the first place. She wrote me
and I advised her to continue taking the mineral
water. She returned to mineral water and the
luminal, with the result that she had no more at-
tacks until the war came and she was unable to se-
cure luminal. Prior to the war luminal was made
only in Germany. When the war came our supply
of luminal was cut off until at the close of the war
an American manufacturer took over the patent and
started to manufacture it. In the interval this pa-
tient had quite a little trouble. Now, however, she
is absolutely free from seizures, her mentality is per-
fectly normal so far as her friends can see, and her
disposition is as kind and lovely as anybody could
wish. I have another case that is different. It is a
convulsive condition, but I doubt whether it is epil-
epsy. A woman about fifty years of age began hav-
ing convulsions at night, these convulsions lasting
for twenty-four hours, and sometimes it was with the
greatest difficulty that Ave Avould get her out of the
conA’ulsiA'e and comatose state following the attack.
General examination Avas negatiA'e; Wassermann AA’as
negatiA’e, and spinal puncture Avas negative. A yeai
ago Ave put her on this treatment and she has had
no conA'ulsions since. The other cases that I haA'e
referred to are epilepsy pure and simple. They all
A'ielded to treatment bA' luminal. I have used a dose
of grain giA-en at night except in a feAA’ cases in
Avhich Ave haA’e giA’en an extra dose for a time. At
times one or tAVO doses a AA'eek is sufficient. The
sodium salt, as Dr. \'oldeng has said, is only one-
half the strength of luminal. During the Avar the
supply of luminal Avas A’ery Ioav and Ave Avere com-
pelled to use a sodium salt Avhere preA-iouslj- Ave had
used luminal straight. I had more difficulty in using
the sodium salt than the luminal, and patients Avere
glad to get luminal again. I haA’e seen betAveen
VoL. XII, No. 5]
Journal of Iowa State Medical Society
179
twelve and fifteen case.s, in all of which the taking
of luminal has enabled the patients to get away from
bromism, and it really has been a wonderful thing.
I do not think that any patients are cured, although
one young girl considered herself so nearly cured —
she had not had an attack for two years and had
dropped the drug for one and one-half years — that
she was married, but about six months after con-
finement, i. e., a year ago, she had a convulsion
after more than two years of entire freedom with-
out taking any drug. She took up the drug again.
I believe that Dr. Voldeng has in hand the trying out
of a most valuable and useful drug, and I am greatly
pleased that he issued the caution he did because of
the danger we may fall into — that of misuse of a
powerful and I believe a most useful remed}-.
Dr. Walter E. Scott, Adel — I would like to ask
Dr. \'oldeng to state whether or not the drug ha^
been used for paralysis agitans, and if so, with what
result?
Dr. Voldeng — In repl\- to Dr. Scott, will saj', we
have had no experience with luminal in the treatment
of parab'sis agitans. I did not intend to discuss thv
treatment of epilepsy' in a general way. iMy' subject
was the use of luminal. I was very' glad, however,
that Dr. Ely called attention to the importance of
general hy'gienic treatment. I am enthusiastic about
the use of luminal. I believe it will prove to be one
of the most useful agents we have, and for that rea-
son I am particularly anxious that you should use
it cautiously and observe carefully its action.
CONSERVATIVE SURGERY OE THE FE-
MALE PELVIC ORGANS*
A. G. Shellito, ]\I.D., Independence
A conservative operation is one that saves a
part or all of an organ that otherwise would be
wholly removed by a radical operation. (Battey
operation — 1st Ovarotomy — 1808 — McDowell.)
Infection and the destructive process following
an infection account for a large percentage of the
pathology' in the female pelvis requiring surgical
interference. Tumors, benign and malignant, and
ectopic gestation are other factors. Of infections
that can be recognized clinically, other than tu-
bercular, there are two, one due to gonococcus
and the other to streptococcus.
Gonorrheal infection is by far the most fre-
quent. It travels along the mucus membrane of
the vagina and uterus to that of the tubes and
may infect the ovaries and peritoneum. Gonor-
rheal infection does not travel through the uter-
ine walls or infect the cellular tissue. When the
pelvic organs are involved the most common loca-
tion is the fallopian tube, resulting in a so-called
*Read before the Austin Flint-Cedar Valley Medical Society, Fort
Dodge, Iowa, November 8, 1921.
pyosolpinx. The initial symptoms are frequent
and ])ainful micturition, when a urethritis is pre.---
ent, with burning and irritation of the vagina
followed bv a profuse leucorrhea. Should the
infection extend, the patient will have pain in one
or both sides of the pelvis, with temperature and
tenderness over the lower abdomen. If the initial
infection is treated promptly and properly, the
uterus and adnexa escape being infected in a
large percentage of cases, as shown by Palmer
Findley and others.
Streptococcic infection follows labor or mis-
carriage, but probably more often, abortion or
uterine instrumentation, such as passing a probe
or using a curette. The streptococcus does noc
follow the same route as the gonococcus, but in-
fects the cellular tissue or parametrium as well as
the uterine wall ; or, you may have a general sep-
ticemia and no localized abscess. If abscess
formation occurs it is lower in the pehds and can
be felt in one or the other cul-de-sac. The dif-
ferential diagnosis is not always easy, particu-
larly if you are unable to get a reliable and com-
prehensive history. I have seen puerperal women
with a moderately high temperature, chills and a
relaxed skin and abdominal tenderness, with a
history elicited of gonorrheal infection ante dat-
ing their pregnancy. Their symptoms were due
to an acute exacerbation of the old gonorrheal
infectation excited by labor.
As the different infectioj^s call for widely dif-
ferent treatment, if you would conserve the life
and health of your patients as well as their pelvic
organs, be certain if possible in all puerperal in-
fections to obtain a correct and reliable history.
Following labor at term, miscarriage or abor-
tion, many women will give no definite history of
infection except that they did not fully recover
from their confinement. In the absence of a
history of gonorrheal infection, this class of pa-
tients with pelvic infection, will usually be classed
under the head of streptococcic infection due to
being infected during or following their confine-
ment, miscarriage or abortion.
Clinical experience in the early history of
pelvic surgery demonstrated that operations done
during the acute symptoms of pelvic infections
wefe nearly always fatal, while operations for the
same trouble done after the subsidence of the
acute symptoms showed a good percentage of re-
coveries. This fact, together with the laboratory
findings, demonstrate that pus resulting from
gonorrheal infection became sterile in a few weeks
or months, at most, after onset of the trouble.
Pus of streptococcic origin may become sterile,
but only after a considerably longer lapse of time.
180
Journal of Iowa State Medical Society
[May, 1922
I believe it is a safe rule, now generally con-
ceded by g\-necologists, not to operate during the
acute or active symptoms of pelvic infections,
this rule being subject to but few exceptions.
Rest in bed, restricted or regulated diet, attention
to the excretions, and ice bag to lower abdomen,
constitute the best treatment if the infection is
gonorrheal. After the lapse of a few months if
the patient is still not free from trouble and a
pus tube can be felt, laparotomy can be done with
a fairly large percentage of recoveries. If given
long enough time these cases nearly all recover.
If the infection is of streptococcic origin with
abscess formation, it will be found lower in the
pelvis and should be drained through the vagina,
or at most extra peritoneally. If the abdomen s
opened and the abscess found high in the broad
ligament, and you have reason to believe the in-
fection is streptococcic, do not drain through the
peritoneal cavity, as streptococcus pus becomes
sterile only after a long period of time, if at all.
In the early days of g\-necolog}’ radical sur-
gery of the pelvic organs was in vogue. Not only
were diseased organs removed, but often healthy
ones as well. Owing to unsatisfactory results,
radical surgery of the pelvic organs grew in dis-
favor and conservative operations were done.
The Battey, or radical, operation for removal of
the ovaries demonstrated that ovulation was not
the only function of the o\aries as their removal
often caused serious nervous disturbance.
Ovaries, or ovarian tissue should be saved not
only for the purpose of ovulation but for the
trophic influences exerted by ovarian function.
Ovarian tissue that does not function is useless;
hence the blood supply of all ovarian tissue must
be conserved or its function and trophic influence
is lost.
Operations undertaken upon women during the
child-bearing period must always consider the
possibilities of pregnancy in women desiring chil-
dren. To become pregnant a woman requires at
least a uterus, one ovaip- or a part of one ovary
that functions, with an open fallopian tube,
though it be but a stump of a tube, on the opposite
side from the ovary. Also when doing con-
servative surgery on the pelvic organs of women
not past the menopause, if impossible to save
organs sufficient for pregnancy, if a part of the
uterus and a functioning ovary can be saved,
menstruation will continue and the patient’s
health is more liable to be recovered, as menstru-
ation is a normal function in woman from pubert\
to the menopause — except during pregnancy and
possibly lactation. (E. H. Ochsner — reprint —
Illinois Medical Journal, May, 1919.)
When infection travels from the external geni-
tal organs through the uterus to the tubes and
other pelvic viscera, the uterus itself does not as
a rule escape entirely, and we find chronic en-
dometritis and metritis with a persistent, though
sometimes not constant, leucorrhea with pelvic
pain, tenderness and dt'smenorrhea.
In the November (1917) number of the Ameri-
can Medical Association Journal, Polak describes
a modification of the Bell-Buettner operation in
which he removes a tube or tubes, as conditions
require, as well as a wedge-shaped piece of the
body of the uterus, saving sufficient functioning
ovary and uterine tissue so that the menstrual
function is not arrested; at the same time remov-
ing all diseased organs. This operation is recom-
mended when the organs are so extensively dis-
eased as to prevent future pregnancy, but where
sufficient ovarian and uterine tissue can be saved
or conserved to still maintain the menstrual func-
tion.
In women prior to the menopause, small ovar-
ian cysts can often be removed and a part of the
ovary with good blood supply left. Fibroid
tumors can be removed leaving most or a part of
the uterus sufficient at least to preserve the men-
strual function. Frequently a number of small
subperitoneal fibroid tumors can be removed leav-
ing the entire uterus, ^^'hen removing a tubal
pregnancy, a healthy stump can sometimes be
saved. If operation is done for malignant dis-
ease, no effort should be made to conserve any
involved organ.
One thousand cases operated on in Cook
County Hospital for tubal infection have been
studied by ^^’oolston and ^\'hite and reported in
the surgical clinics of Chicago for December,
1919. Their conclusions are that conservative
surgery is discouraging, as many of the patients
return for further treatment; that gonorrheal in-
fection practically always involves both tubes and
uterus; that if a woman has survived an acute
streptococcus infection and symptoms remain, de-
lay operation as long as possible as latent organ-
isms are aroused by operation and an apparently
simple case may die of streptococcic peritonitis if
operated on.
In conclusion, from a resume of the abundant
literature from which this paper has been com-
piled, one must conclude that the avoidance of in-
fection is of first importance. If a woman be-
comes infected with gonorrhea, we should always
bear in mind that if not treated properly and
promptly it may jeopardize not only her pelvic, or
child-bearing organs, but her future health. Gon-
orrheal infection occurs in young women. Asep-
VoL. XII, No. 5]
Journal of Iowa State IMedical Society
181
tic obstetric work is the best safe^juard in pre*
venting streptococcic infection. If unfortunate
enough to have a puerperal infection, avoid all
irrigations and douches except to external parts
and do not curette. If labor has been difficult
and the vagina or cervix is torn, apply iodine or
other antiseptic to the erosion.
In infections of the pelvic organs do not oper-
ate until after the acute symptoms have subsided,
if at all. If operation becomes necessary, remove
all diseased organs or parts of organs leaving only
healthy functioning tissue.
Summary
1. Removal of small ovarian cysts, or parts of
a diseased ovary, without destroying the ovary oi
its blood supply.
2. Removing tubal pregnancy and leaving a
healthy stump.
3. Removing fibroid tumors that do not in-
volve the entire uterus, leaving uterus entire or
sufficient to preserve menstrual function.
4. In all pelvic operations to handle ovaries
carefully.
5. Many, if not most, infections of the pelvic
organs get well if time enough is given the pa-
tient. I have had patients married eighteen or
twenty years when first child was born.
6. If surgery is required, remove all organs
that are sufficiently diseased to jeopardize the
patient’s health;
Such, in my opinion, is conservative surgery of
the female pelvic organs.
'COMBINED ANESTHESIA*
Charles Ryan, M.D., F.A.C.S., Des iMoines
In the acceptance of the term combined anes-
thesia we mean to express not only the adminis-
tration of two or more compatible drugs which
produce or supplement the production of surgical
anesthesia or analgesia, but also to incorporate
other important factors which when correlated
may contribute in a large measure to a more sat-
isfactory result to both patient and physician
alike.
For obvious reasons we shall limit our discu.?-
sion to certain methods of combined anesthesia,
and to voice some observations culled from our
experience from a clinical viewpoint during the
last few years. That the ideal anesthesia has not
yet been obtained is conceded by all. However,
in the modern achievements of surgical procedure
'Presented before the Seventieth Annual Session, Iowa State
Medical Society, Des Moines, Iowa, May 11, 12, 13, 1921.
and care, progress in the knowledge of anesthesic
agents has kept pace with asepsis and aseptic
methods, with the standardization of surgical
technique and with greater precision in differ-
ential diagnosis.
Concerning the agents used in the production
of general or inhalation anesthesia, the once pop-
ular chloroform, owing to the necessity of its
careful administration, its high mortality rate,
and its depressing after effects, is being rapidly
renegated to the past.
Ether is the most popular and generally used
agent at this time because of its being the safest
anesthetic in the hands of the novice or occasional
anesthetist, its ease of administration (being al-
most fool-proof) and its low mortality. xMthougli
attended by undesirable after effects.
Nitrous-oxid-oxygen, while not a new anes-
thetic, is rapidly gaining in favor by reason of its
pleasant, rapid induction, its extremely low mor-
tality when administered by an especially trained
'anesthetist, its after effects being comparatively
nil, causing no tissue changes whatever, the drug
being eliminated from the body in from fifteen
minutes to one hour. The chief objections to its
use are the difficulty in transportation, its ex-
pense, and the fact that it is a most dangerous
anesthetic in the hands of one not skilled in its
administration.
Regarding local and regional anesthesia. Car-
roll Allen^ states “while the history of the use of
local means of analgesia precedes that of the use
of general anesthesia, yet the practical use of
general anesthesia preceded by many years that of
local (chloroform 1847, ether 1846, cocain 1884)
and its administration had reached^a high degree
of development before local anesthesia was dis-
covered. Had this not been the case, but the
position reversed and local anesthesia discovered
first, general anesthesia might now be struggling
to displace it from its coveted pedestal, and it is
not to be doubted but that local anesthesia would
have reached a much higher plane of develop-
ment, for in all operations suited to its use, gen-
eral anesthesia cannot compare with it in safety
and comfort.’’
Our convictions concerning the use of local
anesthesia are well expressed by Hertzler^ ;
“Quite apart from the danger is the unpleasant-
ness of inhalation narcosis. The fear of the
anesthetic is not dependent upon ignorance of its
safety. Everyone knows of medical men who
submit to the inconvenience of certain diseases,
such as hemorrhoids or hernias, rather than take
a general anesthetic for their cure. I have been
interested to note the regularity with which phy-
182
Journal of Iowa State Medical Society
[May, 1922
sicians express a pi'eference for local anesthesia
when they themselves are forced to submit to
operation, particularly if they have seen it suc-
cessfully employed upon their patients. If medi-
cal men familiar with the safety of general an-
esthesia hesitate to accept its risk and unpleasant-
ness, we cannot refuse to listen to the wishes of
the layman when he too, seeks to avoid general
anesthesia. !Many patients seek the services of
the charlatan for the treatment of such diseases
as hemorrhoids and hernias, because a cure is
promised them without the use of general anes-
thesia. If the general surgeons were more will-
ing to consider the patient’s viewpoint, fewer
would seek incompetent treatment. If suitable
treatment were offered him at home under local
anesthesia the number straying away from the
ethical practitioners 'would be much reduced.
Problems of this sort demand a conference be-
tween patient and operator. The decision often
will depend upon the patient’s nervous equili-
brium and the surgeon’s skill in the use of local
anesthetics, quite as much as upon the nature of
the operation.”
W hile no hard and fast rules can be laid down
to guide one in the selection of the patient for
local anesthesia in major operation, it has been
our observation that certain nationalities are
more susceptible to pain than are others; that the
robust, vigorous, athletic type, as well as the
highly sensitized nerx ous patient, or the inebriate
or drug addict prove most difficult to handle in
a satisfactory manner. Fortunately, old people
and the class known as “bad surgical risks” have
proven, in our experience, to be the best selection
for local anesthesia. In some instances to allay
the nervous apprehension, it is better to use a
superficial general anesthetic in combination to
attain the desired results.
Assuming that the operator is well grounded in
surgical principles, success in local anesthesia de-
pends upon the following factors; first of all, the
technique must be learned in detail beginning with
minor procedures ; second, thorough knowledge
of regional and relational anatomy is imperative ;
third, respect of tissues, gentle manipulation and
minimizing trauma by sharp knife dissection;
fourth, the operator should proceed with deliber-
ation and without undue haste ; fifth, the patient’s
confidence in the surgeon is very essential. It is
our opinion that in all unsuccessful attempts the
judgment and technique are faulty, not the
method.
In the best possible application of combined
anesthesis, it is assumed that the operator has
primarily mastered local anesthesia.
While cocaine for centuries past was used for
its analgesic effects when applied locally, or for
performing minor operations, its practical appli-
cation in surgery followed the work of the Amer-
ican Surgeons Hepburn, Hall, Halstead, J. Leon-
ard Corning, and others, in 1884-85, and later
George W. Crile, who in 1897 demonstrated its
greater possibilities, la}'ing the foundation for its
almost unlimited use by performing the first pain-
less amputation of the leg after direct injection
of the sciatic and anterior crural nerves. This
case was followed immediately by similar demon-
strations in the clinic of Alatas, Cushing, Hal-
stead, Young and others. Local and regional an-
esthesia have progressively developed until the
present time when many extensive major opera-
tions are being performed daily by this method
without pain, distress or ill effects to the patient.
The abolition of pain from the field of operation
is effected either by;
First — “Paralyzing the peripheral nerve-end-
ings or terminal organs of sensation, as in the
papillary layer of the skin, or;
Second — By blocking or obstructing the path
of all sensorial impressions in the nerve trunk
including the sensory roots in the spinal cord that
connects the field of operation with the sen-
sorium.” Allen.
The high toxicity of cocaine has largely dis-
qualified it for injection methods. IMany sub-
stitutes have been offered. Synthetic preparation
known Xovocaine makes the nearest approach
to the ideal, its injection is painless, its toxicity
being one-seventh that of cocaine, it produces no
deleterious effects upon the tissue, does not inter-
fere with healing, its solution is very stable and
when combined with appropriate amounts of
adrenalin proves most efficacious and can be
used in weak solutions of from one-fourth to
one-half per cent in almost unlimited quantities
for the production of local analgesia.
With apothesine, quinine and urea, we have
had a limited but very satisfactory experience.
Anesthesine we have used successfully in re-
lieving painful wounds.
The use of morphine or pantopan in combin-
ation with atropine or scopolamine as a prelim-
inary hypodermic to either, general or local anes-
thesia really constitutes a combined anesthesia ;
the desirable effects of these narcotics being to
reduce the amount of the anesthetic agent used,
to inhibit salivar}' secretions during inhalation
anesthesia, to minimize the emotional influences
by blunting the sensibilities of the patient, and to
combat the production of acidosis. Chloroform,
ether, and nitrous-oxide produce an increased
VOL.XII, Xo. 5i
Journal of Iowa State ]\Iedical Society
183
acidity of the blood which is proportional to the
depth of anesthesia ; under ether the acidity is
more gradually produced and is more slowly neu-
tralized, while under nitrous-oxide the acidity is
developed rapidly, and is quickly neutralized be-
cause of the absence of tissue changes.
For many years the psychological phase of
anesthesia and surgery has proven a most inter-
esting and profitable study. As a result of our
improved methods of observation, we are con-
vinced that (in addition to an intimate working
knowledge of the drugs to be used) it is helpful
for us to ascertain as thoroughly as possible, not
only the physical but the mental status as well,
and keeping this constantly in mind, during the
preparation period (which if avoidable should
never be hastened) we should endeavor to pre-
pare the mind as well as the body, to safeguard
against the occurrence of psychical as well as phy-
sical shock. We would emphasize that in the
preparation and after care, no detail should be
considered too minute to receive our closest at-
tention, the small things counting here as else-
where, may play an important role in the results
obtained. From this point of view, it is at once
apparent, that the protecting care of a patient
who is to undergo surgical procedure begins when
he is first seen by the physician or surgeon, and
is promoted by a cordial welcome upon his admis-
sion to the hospital, where through the organiza-
tion and training of assistants, nurses, internes,
orderlies, and in fact everyone with whom he
comes in contact, he is received in a kindly and
, courteous manner, his new environment made as
cheerful and comfortable as possible, where man-
ifestedly it is the object of everyone to “play the
patient’s game” and surround him with ever)’
attention and service which will enhance his phy-
sical safety and mental poise. Such care and at-
tention is highly important and should be main-
tained until recover}’ is complete.
In the majority of instances it is a first expe-
rience for the patient, and anticipating a most
unpleasant experience (to say the least) his emo-
tions of fear, worry, and anxiety as to his safety
and survival is drawing heavily upon his reserve
nervous energ}’. In reaction to the stimulation
occasioned by his emotion, the latent nervous en-
erg}’ which he has stored up is being transformed
into active energ}’, which, as a result, is driving
his motor system abnormally fast, and the ex-
haustion which follows will be in direct ratio to
the intensity and duration of the stimuli; this
emotional reaction will be evidenced clinically by
an increase in pulse rate, respiration and not
uncommonly by a rise in temperature. (It would
be interesting in this connection to have a
metabolism test made when the patient is first
seen and before operation is advised, a .second
comparative test made immediately after admis-
sion to the hospital or just before the operation
is begun, providing no sedative or narcotic drugs
have been administered, we would expect an ap-
preciable increase in the metabolism index in the
majority of cases.)
In the prevention of shock by the application
of the principal of Anoci-Association Crile and
Lower^ state; “The argument assumes that phy-
sical action and emotional activity are only ex-
pressions of motor stimulation ; it assumes that
in every active animal and in man are stores of
energ}’ which when released are expressed in
motion or emotion ; that when these stores of
energ}’ are consumed, fatigue or exhaustion is
produced. The stored energy of the body may be
discharged by physical injury of sensitive parts
of the body, by emotional excitation or by physi-
cal exertion.
Assuming that no unfavorable effect is pro-
duced by the anesthetic and that there is no hem-
orrhage, the cells of the brain cannot be ex-
hausted in the course of a surgical operation ex-
cept by fear or by trauma or by both; fear may
be excluded by narcotics and special management
(applied psychology) until the patient is rendered
unconscious by inhalation anesthesia; then, if in
addition to inhalation anesthesia, the nerve paths
between the brain and the field of operation are
blocked with novocaine, the patient will be placed
in the beneficent state of anoci-association and
at the completion of the operation will be as free
from shock as at the beginning. In so-called fair
risks such precautions may not be necessary but
in cases handicapped by infection, by anemia, by
previous shock and by Graves disease, etc., anoci-
association may become vitally important.” And
Sloan^ has aptly said, “The surgeons aim in the
conduct of a surgical case is the return of the pa-
tient to his position in society in the best physical
condition in the shortest possible time, after sub-
jecting him to the least danger and discomfort.”
Our experience during several years past in a
series of approximately two thousand operations
performed by the method of combined anesthesia
anoci-association) has been that our mortality
and morbidity have been reduced one-half by
following as closely as possible the method of
Crile and Lower, the technique of which is;
First — Exalting the patient’s ideas of safety
and well-being by applied phycholog}’, and by the
care of trained attendants in pre and post-opera-
tive treatment.
184
Journal of Iowa State Medical Society
Second — Withholding drastic purgatives, but if
indicated a mild cathartic is given two nights be-
fore operation, a flushing of the bowel on the
following morning and proctoclysis of sodium
bicarbonate-glucose solution by iMurphy drip
method to follow for the balance of the day, and
for twenty-four hours after operation.
Third — The administration of a hypnotic the
night before operation to insure the patient a
good night’s sleep.
Fourth — A preliminary hypodermic of mor-
phine, or pantopan with atrophine or scopalamine
one hour before operation, after which the pa-
tient is not to be disturbed.
Fifth — The avoidance of unnecessary handling
or commotion to and from the operating table.
Sixth — If the case is not to be by local anes-
thesia the administration of a light general anes-
thetic, preferably nitrous-oxide-oxygen with, if
necessary, ether in amount indicated to the
trained anesthetist.
Seventh — Thoroughly blocking the field of
operation with novbcaine and adrenalin in one-
fourth to one-half per cent solution using quinine-
urea in one-sixth per cent solution when indi-
cated.
Eighth — Following the same technique as em-
ployed when using local anesthetic only.
Ninth — Conscientious observance of details in
the after-care until the recovery is complete.
Carroll Allen in his splendid work states .
“The survival or failure of any meihod advo-
cated for practical daily uSe must rest entirely
upon the clinical results obtained. The prime
object of all surgerj-, as well as all medicine, is
the relief of suffering and the prolongation of
life; those measures which attain these ends with
the least disturbance to the patient and the least
suffering must ultimately prevail to the exclu-
sion of all other harsher and less agreeable
methods.”
REFERENCES:
1. Local Anesthesia, Carroll Allen.
2. Local Anesthesia, Hertzler.
3. Anoci- Association, Crile & Lower.
4. H. G. Sloan, Clinic Lakeside Hospital.
At the last regular meeting of the Physician’s
Club of Keokuk, Iowa, on motion of Dr. F. M.
Fuller, it was decided to authorize the treasurer, Dr.
C. A. Dimond, to make a subscription of twenty-five
dollars to the permanent Foundation Fund of the
Tri-State District Medical Society of Illinois, Iowa
and Wisconsin. The subscription was made accord-
ing to the treasurer Dr. C. A. Dimond, to “encour-
age the progress and endowment fund of this re-
markable and unique society.”
[IMay, 1922
THE EDUCATIONAL PHASE OF PUBLIC
HEALTH*
Jeannette F. Throckmorton, Ph.B., A.IM.,
^I.D., F.A.C.P.
State Lecturer for Women
This paper deals with the educational phase of
public health, as experienced in serving under the
Bureau of ^'enereal Disease Control, and does
not touch upon medical or legal measures.
\\'e have the venereal diseases ; these arise
from immorality ; immorality arises from vulgar
sex thinking, and vulgar sex thinking begins in
early childhood. Here we see the vicious circle,
and if we wish to make any permanent impres-
sion upon the venereal diseases we must begin
with the young generation now arising.
The former policy of tabooing all reference to
sex is vicious ; such action gives the child the
imjiression that all sex is so impure and so vulgar
that even dear mother cannot mention it, and a
salacious impression is indelibly printed upon the
child’s mind. It is not a question of whether a
child shall receive knowledge of sex matters or
not, it is only a question of what knowledge a
child shall get ; and not the actual knowledge so
much as the attitude.
It is a fact that unsatisfied curiosity often
drives a child to undesirable sources of informa-
tion ; for curiosity concerning life is a natural in-
stinct and should arise in a child’s mind unless he
is feeble-minded.
Traveling over Iowa the past two years as
State Lecturer for Women, experience has led '
me to decide that the majority of girls in this
state receive no home instruction of any kind
whatever on sex matters. It is doubtless the
same with boys.
Schools do not supply this knowledge. Not
one high school in which I have been, has a well-
planned constructive method of giving sex edu-
cation. ]\Iany high schools approached it by most
excellent nurses who gave courses in Home Eco-
nomics, but who all felt that they should not be
expected to teach a subject so difficult as sex
education without special training in the modus
operandi ; and in some schools where the nurse
had attempted such a course the mothers ob-
iected. These mothers had not instructed their
daughters and did not want anyone else to do so ;
and when interrogated regarding who should in-
struct their daughters airily replied that girls get
this information by instinct. Yes, instinct and
vulgar companions. One junior high school had
*Read before the Seventieth Annual Session, Iowa State Medical
Society, Des Moines, Iowa, May 11, 12, 13, 1921.
VOL.XII, No. 5]
Journal of Iowa State Medical Society
185
splendid preparation for sucli a course to follow
later; and it was a delight to hear the children
in a seventh grade reciting on Gulick’s “Next
Generation,” and to feel that they were getting
that sense of personal responsibility toward their
future children.
Since homes have failed to give this exceed-
ingly important education to the child, schools
will have to devise some plan that can be safely
followed, so that the next generation will be bet-
ter prepared to meet the problems of sex relations
than have the adults of the present time.
Sex education in schools should never be given
as a separate course, but made a part of other
studies. In botany, biolog)', physiolog)', physical
education, domestic science, even in literature, the
laws of physiolog)' and social ethics may be taught
naturally ; so that children attain a wholesome at-
titude toward sex.
But not every teacher can teach sex topics well ;
she must have aptitude and be specially trained,
or she will do more harm than good if she at-
tempts this special phase of class work. You
would not expect the mathematics instructor to
teach manual training, or the latin instructor to
teach music ; then why think that any teacher it.
capable of teaching this difficult subject?
No parent however poorly prepared or even if
he cannot give scientific facts, can but have a
good reaction when he truthfully answers his
child’s questions as each arises, never putting the
child off on any pretext whatever. This is the
part of the education of the child that pre-emi-
nently belongs to the parents, but only too often
they shrink from their duty and neglect it.
As observation is the natural way in which a
child gains knowledge, we may be able to utilize
this method through motion pictures ; and this
would eliminate the problem of specially trained
teachers. The material for such motion pictures
would have to be carefully chosen by a selected
group of physicians, educators, psychologists and
parents ; so that the facts presented on the screen
would be scientific and yet would result in the
right reaction of the child to the knowledge pre-
sented, without undue shock or arousing purient
curiosity. This part of the program cannot be
hurried, but must be worked out without undue
haste.
The educational phase in venereal disease con-
trol in Iowa was started in July, 1919, practically
two years ago, and since that time has reached
close to 165,000 girls and women in over 1000
lectures.
These lectures were given to all classes of
women; high school girls, college women.
women’s clubs, parent-teacher associations,
women in industry and business. If occasion pe;'-
mitted, time was always given for questions and
conferences following the lectures, when the girls
might come singly or in groups and ask ques-
tions; and this was especially valuable in high
schools and colleges. IMany showings of the
movie “The End of the Road” were made, like-
wise the movie “How Life Begins.”
Special effort was made to work through the
educators of the state. The State Superintendent
of Public Instruction has cooperated splendidly,
the county superintendents likewise, resulting in
many lectures before teachers institutes. Su-
perintendents of city schools almost unanimously
turned over their schools to the speaker for lec-
tures and conferences and the movies; and the
same spirit of interest prevailed among colleges
and universities, where hours for conferences
were scheduled far in advance with various
groups of girls, and invariably the request came
for more lectures with more time allotted for
conferences.
There is great demand for, and tremendous
possibilities in this educational phase of public
health, and the thinking men and women of
Iowa are deeply interested in it, and this problem
must be met in a wholesome and sane way.
Discussion
Dr. Paul E. Gardner, New Hampton — It is ver’'
difficult for any of us to discuss a paper of this kind,
at least it is for me. I realize, and I think all of us
do when we think of the sex proposition, that along
educational lines is the only way we can ever ac-
complish anything. But, as the essayist said, it is a
very difficult problem to handle, and one hardly
knows where to begin or what to say. It is a good
deal like the question that came up twenty-five years
ago in the experience of those practicing in the
country, when, to the suggestion that a trained nurse
should be employed to care for the case, the answer
was, “Oh, my! we can’t afford it.” It was a new
thing. And it is the same way today in trying to
send a patient to one of the smaller hospitals: “Oh,
no!” People had the idea that every patient sent to
the hospital would die. I know that was the condi-
tion in our little town when we first had a hospital —
they thought every one who went to the hospital
certainly had to die. The good work that Dr.
Throckmorton has been doing cannot be measured in
money, for no one can estimate what will be the
results of the magnificent work that she has been
doing over the State of Iowa. I have the pleasure
of being on the committee on Health and Public
Instruction, but Dr. Throckmorton does the work.
Dr. Albert and I get a little glory from the work
she has been doing, simply because we are on the
committee. But we do not do much, I am sorry to
186
Journal of Iowa State ^Medical Society
[^Iay, 1922
say. If all of us would give talks or lend our influ-
ence as Dr. Throckmorton has been doing, what a
beautiful country this would be to live in, how much
better humanity would be in the future. She is cer-
tainly doing a wonderful work.
Dr. Frank M. Fuller, Keokuk — I have a word to
say in appreciation of Dr. Throckmorton’s work and
her address this morning. I think we all, even as
medical men, appreciate the difficult position, and
yet it should not be difficult. Last night we ap-
plauded to the echo the sentiment that of all the
wonderful crops that are raised in Iowa, our boys
and our girls are the primary products of the state.
Those of us who have boys and girls growing up in
our homes, realize the absolute fundamental truth of
that statement. We come here and talk of our scien-
tific problems, we go home and work along our
specialized lines, and we think that that is what we
are working for. And yet every one of us knows in
our heart that our ambition, our hope, our life, is
settled in that home where the child is growing up.
We wonder what he is going to be, we wonder what
she is going to be; if it is a boy we are looking for-
ward not to his success in material things, but that
he grows into a than — a man that can stand before
all men, a man of honor, a man of truth, a man of
position. Now, what does it mean? We are virile,
we know what we are talking about, we know as
medical men what this matter of sex means to
people, and yet somehow we sort of shy away from
it; we look at it from the venereal side, we look at
it from the health side; we do not realize that the
sex impulse, next to self-preservation, is the funda-
mental thing because it is behind the great founda-
tion of human life, and that is reproduction. How is
your boy getting at this? You are looking forward
to your boys’ and to your girls’ future and what they
are growing up for. We all have our children come
to us with questions that they ask us, and we as
medical men hardly know how to answer them. I
know children in the adolescent period who have
from six to seven years of age grown into a natural
knowledge of how the corn filters down its pollen
on to the silk and how it fertilizes itself and how it
comes out into a reproductive grain. I have had
children bring in butterflies that are in a very unique
situation for a child to find a butterfly in, and they
ask what it means; they find their pets — their rabbits,
their guinea-pigs, etc. — reproducing. Do you suppose
vour child, of whose intelligence you are proud, is
going to sleep as we are going to sleep? Their
whole life is a question mark — they are asking about
everything. My boy came to me when a little fellow
and said: “I heard a boy say, ‘If you don’t stop that
I'll knock hell out of you!’ What did he mean?” I
could hardly tell him what he meant. But they are
asking questions of every kind. The Doctor suggests
that in the schools, through the processes of biology,
physiology, etc., these children can be taught the
normal, natural things. I think that we can teacn
our children that they can talk about something in
the home, that they cannot talk about outside. You
teach your children their natural attitude towards the
normal functions of the body; they do not come into
the parlor and talk about what has occurred after
breakfast. And yet you know that you teach the
children to come to father or mother and talk very
frankly about the normal functions of the body as to
what has happened to them, as to whether they are
normal, regular, or performing the normal functions
of the body as we know are necessary to health, i
believe that naturally we reveal our personal experi-
ences along these lines with considerable hesitancy,
but I know that boys can talk in the home with their
parents about some of the deeper underlying func-
tions of the body, as normally as they can about
some of the common, ordinary functions of daily
life. But, because you do not expect your boy to go
in among your guests and talk about the normal
functions of the body, you can teach him that those
things also he can talk to his father and mother
about. The deep, fundamental things that he can
talk to his father and mother about, are not the
things he will go out and talk to his companions
about any more than he would talk about the natural
functions of the body. Therefore I think that, as
medical men, looking at these things in the right
way (and we can only look at them as we do, from a
high plane, controlling our own impulses along nor-
mal lines) — we can as medical men instruct our fam-
ilies primarily, and also we can instruct intelligent
parents, to whom we owe responsibility along such
lines as this, in a commonsense, intelligent way. I
appreciate Dr. Throckmorton’s work.
Dr. Throckmorton — I am glad that Dr. Fuller
spoke of self-preservation and race preservation.
From the time of childhood, even before the adole-
scent period, these sex impulses come up, and if we
did not have them what would become of the race?
.\nd if there were no love or sympathy in the world,
where would art and literature be? Most of our
songs are about love, our paintings give expression
to love, the finest in literature have love as a basic
theme, and love is one of the things that makes life
worth living. And I am delighted that Dr. Fuller
brought that point up. I am also pleased that he
mentioned the fact that if parents will talk sex mat-
ters with their children, this will make a bond of
confidence between them. I do not know the psy-
chology of men, but I know that if a mother does not
answer her child’s questions on sex just as they come
up, early, she loses the opportunity to establish this
bond of confidence. The child maj^ be only four or
five years of age when she will ask, “Where did I
come from? — where did you get me. Mother?” And
if the mother does not answer the question truly,
she is going to lose the bond of confidence. I pre- '
sume it will be the same way with fathers and sons.
I do not know the psychology of men folks. The
question that is asked me more than any other, is
this: “Doctor, will you not please tell me, in words
of a, b, c, how I may explain to mj^ child the be-
ginnings of life?” And these questions also come:
“How may I tell about motherhood to my little
VoL. XII, Xo. 51
Tourxal of Iowa State ’Medical Society
187
girl?'’ “My boy is asking about fatherhood, and liow
am I going to answer this?” The mother says, “My
daughter is twelve years old, and when this delicat *
subject comes up how will I tell her about the change
that will come to her? Please tell me how to do it.”
And these are the questions that come up, rather
than those about venereal diseases, of which the
mothers are ignorant, and therefore do not know
enough about to fear. I want to thank Dr. Gardne*"
for all the nice things he said about my work in this
field. But I feel that he should give a great deal of
credit to the Iowa State Board of Health, which
made possible this department of health and public
instruction. There are five other women doctors who
are doing this work in various states. Dr. Ulrich of
Minneapolis was really the first one to start this
work in the Alid-West. So the State of Iowa de-
serves the thanks, not myself, and, anyw'ay, you re-
member that “flattery is the food of fools, but now
and then we men of wit will condescend to take a
bit.” In conclusion, we must have confidence in
what we are saying. We must believe in what we
say or we will not get it “put over.” Many people
say to me, — Doctor, aren’t you rather embarrassed
to talk about these things in public and to groups
of women?” I believe that if we approach the prob-
lem of sex education and venereal disease control
shamefacedly or with a timid touch, we are going to
do more harm than good. In this connection, I like
to remember that remark from Emerson: “What
you are in your heart, thunders so loudly I cannot
hear what you say to the contrary.”
TUMORS INVOLVING THE ORAL CAV-
ITY, UPPER RESPIRATORY PASS-
AGES, AND EARS, AND SOME OB-
SERVATIONS EOLLOWING
THE USE OF R.ADIUM*
Margaret Armstrong, M.D., Iowa City
Of all the tumors involving the maxillae the
epulis is most frequent. Epulis is a name often
used loosely as a topographical term to designate
any tumor apparently arising from the gums or
gingival margin. For this reason it would be
well to discard it altogether. But there is a well
recognized tumor for which I can find no other
generally accepted name — the inflammatory or
fibrous epulis. This is a grow’th half inflamma-
tory and half neoplastic in character. It springs
from the periosteum or the connective tissue un-
derlying the mucosa at the gingival margin. As a
general rule, it is preceded by an inflammatory
reaction such as pyorrhea, a tooth broken below
the margin of the gum or a deposit of tartar. Oc-
'Presented before the Seventieth Annual Session, Iowa State
Medical Society, Des Jloines, Iowa. May 11, 12. 13, 1921,
Section Ophthalmology, Otology and Rhino-Laryngology.
casionally a tumor of this nature arises deep i'l
the socket of an apparently sound tooth. These
tumors affect the iqiper and lower jaw with equal
fre(|uency. They most commonly a]i])ear in the
region of canine, the cuspid and the incisor teeth.
They are most frequent in young people, and
much more frequent in women than in men. It is
a slow growing tumor with no tendency to in-
filtrate the surrounding tissues or to spread by
metastasis. It rarely ulcerates, is covered with a
normal appearing mucosa, it is hard and firm to
the touch, is adherent to the periosteum of the
underlying bone. It is sharply demarcated from
the surrounding tissues and there is no inflamma-
tory or infiltrated border around it. If it is thor-
oughly removed it does not recurr, but if partially
removed it will return and in a more malignant
form so that sooner or later if meddlesomely
treated it may become a true fibro or small round
cell sarcoma.
Histologically, the tumor is composed of a mass
of fibrous tissue resembling scar tissue. In most
instances there is an infiltration with wandering
cells — lymphocytes, plasma cells and endothelial
cells. Foreign body giant cells are sometimes
present in small numbers.
Another type of relatively benign tumor which
occurs quite frequently in the jaw is the giant cell
epulis or giant cell sarcoma. This tumor also oc-
curs in other portions of the body, especially at
the ends of the long bones, in the capsule of the
joints, in the bursa and tendon sheaths. How-
ever, its most frequent site is on the maxillae. It
may be quite destructive locally but has no tend-
ency to metastasize. It occurs on the gingival
margin or in the socket of an extracted tooth. As
a usual thing it grow'S very slowly and does not
infiltrate the suri'ounding tissue. It is softer and
redder than the fibrous epulis, bleeds more easily
and exhibits more tendency toward ulceration.
It is more often found on the lower jaw than the
upper and is more frequent in women than in
men. It occurs more frequently in young people
than in the aged. Occasionally this tumor may
arise from the endosteum where growing cen-
trally it absorbs the marrow and the bone and
pushes out the periosteum, which being stimulated
to renewed activity produces a wall of new bone.
By this continuous method of production and ab-
sorption of bone the jaw may reach several times
its original diameter before the tumor breaks
through and invades the adjacent soft tissue. If
a giant cell epulis is incompletely removed it re-
turns in a more aggressive and destructive form.
However, it is rarely necessary to do a resection
of the jaw but suffices to sacrifice two or three
188
Journal of Iowa State jMedical Society
[May, 1922
teeth and make a wide incision leaving a narrow
border of normal tissue about the tumor.
In addition to the giant cell sarcoma we often
have sarcomas of the round cell, the spindle cell,
mixed cell and melanotic type arising in the jaw.
The mixed cell sarcomata which occur here are
fibro-sarcomata, osteo-sarcomata, chondro-sar-
comata and possibly mixo-sarcomata. The round
cell and spindle cell growths are very malignant.
Their course is short and unless successfully
treated they always end in death. No matter how
thoroughly they are removed their tendency is
toward local recurrence. However, they exhibit
little tendency to spread by metastasis to other
portions of the body. The lymph glands of the
neck are frequently swollen but this is due to the
marked inflammatory reaction which usually at-
tends these tumors. The mixed cell tumors are
less malignant than the round or spindle cell sar-
comata. They var}- in this respect according to
the relative amount of undifferentiated sarco-
matous tissue which the tumor presents. Sar-
comata of the more malignant types are much
more common in the superior than in the in-
ferior maxilla. Very frequently they arise in the
antral wall or in the nasal or orbital portion of
the superior maxilla and by direct extension reach
the aural cavity, where their presence may be
noticed for the first time. Sometimes the spindle
and small round cell sarcomata have a long ante-
cedent history of sinusitis, frequently with a com-
plicating osteomyelitis. This fact has been es-
pecially noticeable in cases which we have seen
at the S. U. I. Clinic.
The melano-sarcomata when found in the
maxillae exhibit the same characteristics which
they display when found elsewhere. They have
more of a tendency toward metastasis than any
other tumor found in this region. Malessez re-
ports nineteen cases of melano-sarcoma of the
jaw, seventeen of which occurred in the upper
jaw. Another interesting group of tumors found
in the maxillae and not elsewhere are the odonto-
mata which arise in embryonic rests from the
anlagen of the teeth. These new growths may be
cystic or solid tumors or a combination of both.
Early in embryonic life there is formed the
dental ridge which is produced by a piling up of
epithelial tissue. After the formation of the ridge
the mesoblastic tissue on either side grows more
rapidly than that immediately below it so that it
soon becomes a groove, and later a deeply in-
vaginated plate of epithelial tissue. From this
plate buds are thrown out and grow still farther
down into the connective tissue which is soon to
be converted into the bony tissue of the maxillae.
The buds correspond in number to the teeth which
are to be formed. First the buds for the milk
teeth grow down and a little later these from
which the permanent teeth are to be formed
push off to one side. Immediately below each
descending bud small areas of connective tissue
take on special characteristics. They become verv
cellular and the nuclei of the cells assume the ap-
pearance of rapid growth. These specialized cells
are the odontoblasts, the anlagen of the dentine of
the teeth. They interrupt the farther descent of
the buds which continuing to grow become in-
vaginated and partially surround the odontoblasts.
We have now the rudiments of the teeth — the
odontoblasts- capped by the enamel organs.
The dental plates and the dental buds have now
performed their function and retrogression ha?
already begun. The dental plate becomes cribri-
form and after a time is represented only by an
isolated group of cells here and there. When the
teeth are fully formed no trace of enamel organ,
tooth buds or dental plate should be left. How-
ever, retrogression is often more or less incom-
plete and rests of epithelial cells are left behind
in the fully developed jaw. The rests are spoken
of as paradental debris.
An appreciation of these embryonic facts af-
fords the only basis for an adequate explanation
of the origin and development of dental tumors.
The normal process of development and regres-
sion may be interrupted at any point and any of
the remnants left are at times capable of new
growth. All tumors arising from such rests may
be classified as odontomata. These tumors ex-
hibit great differences in their anatomical, histo-
logical and clinical aspects. They range from
simple benign to solid, rapidly growing carcin-
omata and other malignant tumors which closely
simulate sarcomata and endotheliomata.
The simplest tumors are the so-called root
cysts ^^•hich are formed about the apeces of dis-
eased teeth. The root of the tooth becomes in-
fected and the irritation causes the epithelial cells
which as remnants of the enamel organ are quite
generally found at the apex of the teeth to take
on new growth. As the cells multiply those at
the center are shut off from their source of nutri-
tion and degenerate, leaving at the center a cyst-
like cavit)- which may be filled with serous fluid,
mucus, fatty, caseous or inspissated material.
The walls of the cavity are lined with epithelial
cells which may be either columnar or squamous
in type. It sometimes happens that the infective
material reaches the cystic cavity and destroys in
part or completely the epithelial lining; in which
case we have a cavity lined with granulation tis-
VoL. XII, No. 5]
Journal of Iowa State Medical Society
189'
sue or scar tissue and the contents may be pur-
ulent. Dental cysts are also found at the roots of
sound teeth. Their formation is identical to that
of root cysts just described excepting that the
factor which stimulated the epithelial cells to a
state of new growth is unknown as indeed it is in
most neoplasms.
d'he simple dentigerous cyst which contains a
single well formed tooth arises from the enamel
organ which persisting forms a cyst-like cavity
about the tooth and prevents its eruption. In
such cases there is always a missing tooth. This
mishap seldom occurs in conjunction with the
milk teeth. Most often the wisdom tooth is the
one involved. The canines and the molars are
next in order of frequency, the incisor teeth being
most rarely involved. Some of the dentigerous
cysts contain more than one rudimentary tooth.
As many as twenty-five to sixty may be found
within a single cyst. These are not well formed
teeth but merely irregular bits of enamel and
dentine. They arise fi'om rests which represent a
much earlier embryonic stage than the fully de-
veloped enamel organ. Dentigerous cysts may
also arise from the arrested development of aber-
rant teeth. One such case was that of a negro
woman operated on in our clinic who had high
in the ramus of the mandible near the bifurcation,
a' cystic cavity containing a well developed normal
tooth. They have also been found in the hard
palate, the zygomatic region and in the orbital
portion of the superior maxilla.
The multilocular cysts also arise from the para-
dental debris. They merely represent a more
complex and lawless growth. The cyst cavities
may be smooth walled or show many papillary
growths. The walls are of fibrous or cellular con-
nective tissue. Calcified areas and areas of bone
are frequently present. Dentine, enamel and
rudimentai'y teeth are also occasionally seen. The
cellularity of the fibrous tissue in certain areas
may be so marked as to give the histological pic-
ture of a sarcoma or myxo-sarcoma. Ewing
thinks it probable that by exaggeration of this
process apparently pure sarcomata may arise.
The cystic tumors have little or no tendency to
spread by metastasis but the more lawless ones
may at times be locally, very aggressive and small
ramifying cysts may spread deep into the can-
cellous bone.
The solid odontomata have the same origin and
many of the same characteristics as the cystic
tumors. The only real difference being in their
tendency to form cysts. The epithelial cells may
take on an appearance very similar to that seen
in an epidermoid carcinoma. Pearl formation
may be abundant. It does not seem strange that
this should be true when it is remembered that
they originally spring from the epidermoid epi-
thelium. Alany of the tumors show dense areas
of columnar cells interspaced with areas of
enamel and dentine. A common form is the plex-
iform odontoma made up of numerous twisting
convoluted columns of small spindle cells. These
tumors represent an uncontrolled effort on the
part of the new growth to reproduce the same
structure which we see in the tooth buds in nor-
mal embryonic development. (B. Fischer found
a tumor having the structure of an odontoma in
the tibia. He attributed it to the continued down-
ward growth of a tooth bud.) The plexiform
odontomata often contain numerous small cystic
areas which give the growth an alveolar appear-
ance and may lead to the diagnosis of an adenoma.
It seems to me that this alveolar structure is most
logically accounted for on the ground that it is
an abortive effort on the part of the neoplasm to
reproduce the enamel organ. IMany odontomata
have an abundant and very cellular stroma. We
have noted in discussing the embryology of the
teeth that as the bud pushes downward the meso •
blastic tissue immediately below it becomes very
cellular and takes on the characteristic appear-
ance of actively growing tissue. This must be in
response to some influence exercised by the
epithelial cells and it seems quite plausible that
this power to stimulate connective tissue to ac-
tive growth may be latent in these cells and that
it may be reassumed to an exaggerated degree in
some of these lawless new growths. This theory
explains the markedly sarcomatous appearance
which the stroma of these tumors sometimes dis-
plays.
The odontomata are essentially tumors of youth
and young adult life. Although in a few well
authenticated cases they have occurred in old age.
The simple cyst occurs more frequently in the
inferior maxilla. The more complex solid tumors
are more frequently in the superior maxillae. The
simple cysts are very slow growing and very be-
nign although it is possible that meddlesome and
inadequate attempts at their removal may cause
them to return as a more destructive growth.
The adamantinomata are very destructive locally
but have little tendency to metastasize. Occa-
sionally they become exceedingly malignant and
metastasize freely. This is especially apt to oc-
cur following imsuccessful attempts at remov^al.
Ewing reports a typical case of plexiform odon-
toma, which after five attempts of eradication
had entirely lost its original epithelial character-
190
Journal of Iowa State Medical Society
[May, 1922
istics and closely resembled a perivascular sar-
coma.
Carcinomata of the oral cavity arise from the
mucous membrane of the cheek, the floor of the
mouth, the gums, the palate and the tongue. From
whatever point they originate they have not far to
spread without involving the maxillie. Carcino-
mata which arise in the antrum and lateral por-
tions of the nasal wall mucosa also involve the
superior maxillae and in this way group them-
selves inseparably with the tumors of the oral
cavity. Because of this relation of the superior
maxillae to the nasal mucosa carcinomata are
much more frequent in the upper than in the
lower jaw and they also represent a much greater
variety of clinical and histological attributes.
Carcinomata more frequently involve the max-
illae than do sarcomata, their relative number be-
ing about three to two.
Carcinoma appears somewhat later in life than
sarcoma. The periods of greatest incidence being
the fourth, fifth and sixth decades. Cancers of
the oral cavity are five or six times as common
in men as in women. The relative number of
cancers of the mouth as compared to cancers aris-
ing elsewhere in the body is high and their fatality
is very great being variously estimated from 75 to
90 per cent.
The importance of chronic irritation as an
etiological factor in carcinomata of the buccal
cavity has been much under estimated, not only
by the laity but by the medical profession as well.
All chronic ulcers and fissures may act as a pre-
disposing factor in the establishment of a malig-
nant growth. Leukoplakia also is a very import-
ant factor in this respect. According to Fourner
it is followed by carcinoma in 30 per cent of the
cases but many authors hold all lesions under susy
picion and there is no doubt but that the disease
has a definite tendency to become malignant and
should always be treated as a precancerous lesion.
A diffuse papillomatosis of inflammatory origin
is sometimes seen on the buccal and lingual mu-
cosa and is a frequent precursor of cancer. The
long continued irritation from the edge of a
broken tooth or from pyorrhea seems in many in-
stances to stimulate the epithelium to an increased
activity which ends in malignancy. Chronic ini-
tation from the use of tobacco also seems to be a
predisposing cause.
Carcinomata of the cheek and inferior maxillae
metastasize to the sub-maxillary lymph nodes. A.s
a rule meta.stasis from the inferior maxillae is
early, from the cheek late or not at all. When the
cancer is in the superior maxillae there is little
tendency to metastasis. Ewing thinks that as the
lymph drainage from this part is into the deep
glands along the internal maxillary artery and
consequently difficult or impossible to palpate
even though enlarged, metastasis is probably much
more common than has been thought.
In carcinoma of the tongue and the floor of the
mouth metastasis occurs earlier and more uni-
formly than from any other portion of the oral
cavity. In all cases the metastasis is usually to
the same side as that on which the lesion is sit-
uated but the lymphatics of both sides are some-
times involved and occasionally it happens that
the opposite side is involved while the affected
one remains clear.
The great majority of buccal cancers are of the
simple acanthomatous type. The basal cell type
is rare. Occasionally a tumor is found in which
the cells and arrangement are such as to suggest
that it arose from the ducts of a mucous gland.
In the upper jaw we have the malignant odonto-
mata which must be classified with the carcino-
mata and uncommon forms which may arise from
the nasal mucosa. These are adenocarcinomata,
columnar cell carcinomata and a rapidly growing
veiy malignant neoplasm which because of the
type of cell and arrangement strongly resembles
a perivascular sarcoma and is perhaps frequently
mistaken for it.
The neoplasms of the pharynx and tonsils con-
stitute a most interesting group. I regret that
there will not be time for me to go into them in
any detail.
Benign papillomata are not uncommonly found
on the soft palate, uvula, pillars of the fauces and
on the surface of the tonsil. They may be sessile
or pedunculated. They are grayish or red in color
and vaiy- in size from a millet seed to a hazel nut.
They are composed of a core of fibro-vascular
tissue and covered with fimbriie of stratified
epithelium.
Adenomata arising from the mucous glands
occur in the palate, the uvula and the tonsils.
They are firm, smooth growths usually pink or
gray in color and probably can onl}’ be diagnosed
with the microscope. In several of the cases
which we have seen at the Iowa City Clinic they
have occurred shortly following rather mutilating
tonsillectomies.
Lipomata and angiomata may be found in the
pharynx but they are extremely rare. Dermoid
cysts and teratomata are perhaps as frequently
found in this region as in any other but they are
chiefly interesting curiosities because they are
rarely found in those who live long after birth.
Mixed tumors of the parotid may be found here.
Pedunculated growths as large as marbles some-
VoL. XII, No. 51
Journal of IoWa State Medical Society
191
limes hang from the surface of the tonsil which
on removal are found to consist of ordinary ton-
sillar tissue. The occlusion of the opening of a
tonsillar crypt may produce a retention cyst. The
contents of these cysts vary from serous fluid to
a thick substance resembling sebaceous material.
Recently Sir St. Clair Thompson has reported
cases in which accumulations of calcareous ma-
terial within a tonsillar crypt produced some in-
flammation and pain in the tonsil and on palpa-
tion give the characteristic hard, boardv feeling so
characteristic of cancer. A probe passed into the
mouth of the crypt easily revealed the true nature
of the malady.
Sarcomata may arise in the tonsil or may start
in the fauces, the palate or the posterior wall of
the pharynx and spread to the tonsil. All his-
tological types of sarcomata may be found. In
1912 Justus Mathews, then of Rochester, Minne-
sota, reported eleven cases. Of these, all but one
were mixed, round and spindle cell sarcomata.
One was a lynniho-sarcoma. W'hile these tumors
are not so hard and rigid as carcinomata, they
are usually firm but in some cases feel somewhat
soft and cyst-like. There is as a rule little infil-
tration beyond the margin. Hence, a sarcoma
may remain more or less encapsulated for some
time while the growths increase \ery slowly or
appear to recede. When it extends it is gener-
ally toward the angle of the jaw and extensive in-
volvment of the lymph glands then appears in the
neck. On the whole, pain, ulceration, induration
of surrounding tissue and early glandular involv-
ment are much more prominent features of car-
cinomata than sarcomata. Sarcomata of the ton-
sil may run a rapid course or may extend over
years. This is particularly true of lympho-sar-
comata. While some are rapidly fatal others are
so benign that they should probably be called
lymphomata rather than lympho-sarcomata.
Wright and Smith report a case which began as
a recurrence of a tonsil which had been removed
for hypertrophy. Sections showed nothing to
distinguish the first recurrence from ordinary
tonsillar structures, ^^’ith each recurrence the
growth took on more and more the typical form
of a malignant lymphosarcoma. L. W. Dean has
also reported the case of a man whose tonsils
were removed and promptly recurred. Following
this large tumor-like masses were removed at
varying intervals, not only from the fauces but
from other portions of the pharyngeal lymph
ring over a period of four years. The man finally
died from pneumonia but in all this time the
tumor did not become destructive in its growth.
Some years after the man’s death I looked over
the sections made from this tumor and found it to
be composed of small cells which were in every
respect similar to normal lymphocytes. There
was no variation or irregularity in size of the
cells, no mitotic figures and none of the usual
signs of malignancy. There was, however, no
attempt at normal lymph gland structure, no
germinal centers, no sinuses, nothing but masses
of lymphocytes and the smallest possible amount
of stroma. However, from the tissue which was
removed at the last operation I found a some-
what changed picture. There were areas in which
the cells were large and irregular and many
mitotic figures were found. Had the man lived
he would no doubt have succumed to the malig-
nant growth.
Primarv carcinoma of the pharynx and tonsils
is of rather rare occurrence. This is partially
true in regard to the tonsil. W’right and Smith
quote statistics compiled from .50,000 cases of
cancer in which cancer of the tonsil occurred
twenty times. They think, however, that the
actual ratio must be higher than this. iMathews
reports eleven cases of cancer of the tonsil from
among his patients and collected twenty-one from
the literature.
Carcinomata arise from the base of the tongue,
from the tonsils, from the posterior wall of the
pharynx and the fossie of Rosenmuller as some-
what wart-like papillomata which have a marked
tendency to ulcerate. They are extremely inva-
sive and are surrounded by a deep border of in-
duration and inflammation. The edges of the
ulcer are very hard and knobby. Metastasis
through lymphatics is early and extremely promi-
nent and is often to both sides of the neck. They
usually run a very rapid course. Of the thirty-
two cases in Alathews’ report only three were
known to be alive after three years and these had
been treated by tonsillectomy and cautery.
The histological picture is that of an epidei'inoid
carcinoma but the growth is rapid and differen-
tiation of the cells so poor that they often resem-
ble rapidly growing mixed cell sarcomata, es-
pecially in the metastasis to the lymph nodes.
Tumors of the nasopharynx, either malignant
or benign, are exceedingly rare. Papillomata have
been reported. Adenomata and cysts chiefly m
connection with involuting adenoids may occur
Nasopharyngeal polyps have their origin in the
antrum of Highmore. They have a long stalk
which grows out through an accessory osteum.
The distal end spreads out into a large pea^-
shaped mass which hangs down into the naso-
pharynx. They have the same structure as nasal
polyps. They do not represent new growths bul
192
Journal of Iowa State Medical Society
[May, 1922
merely mucous membrane which through inflam-
matory changes has lost its elasticity and be-
come permanently oedematous and saculated. The
cells become water-logged and resemble some-
what myxomatous tissue. Polyps often contain
large mucous cysts which are formed as the re-
sult of obstruction in the ducts of the mucous
glands. All the inflammatory changes to which
the mucous membranes of the nasal cavity aie
subject may be observed in polyps. Because of
their position the choanal polyps are particularly
subjected to inflammatory changes and not in-
frequently become gangrenous. In some cases
choanal polyps may originate in the sphenoidal
sinuses or the posterior ethmoidal cells. Fibro-
mata of the nasopharynx are reported by a num-
ber of authors. They must not be confused with
fibrous tumors arising in the nose and passing
backward into the pharynx. They originate from
any part of the fibrous tissues of the naso-
pharynx— the basilar fibro-cartilage, the surface
of the basi-sphenoid or the bodies of the upper
cer\ical vertebrie. The commonest point of
origin is probably the periosteum over the base of
the sphenoid bone. They vary greatly in size.
Their etiolog}' is obscure. They are rare in fe-
males and occur in males from the age of ten to
twent\--five years. They are benign in that they
have no tendency to infiltrate or to spread by
metastasis or to recur after removal. But they
are clinically malignant in that they fill all the
available space and then by pressure on adjaceiit
structures cause atrophy and absorption of the
bone and not only grow down into the pharynx
but extend into the nose, the paranasal sinuses
and even into the orbits and the cranial cavity.
According to St. Clair Thompson the tumor is
composed "wholly of fibrous tissue, it is very cel-
lular and not uncommonly many of the cells
strongly resemble those found in spindle and
round cell sarcoma. It is quite vascular. The
blood-vessel walls are of embryonic tissue. If
these tumors do not reach a size incompatible with
life until the age of adolescence is past they have
a tendency towafd spontaneous disappearance.
Simple fibromata are sometimes found in the
nasal cavity and arise from the ends of the tur-
binates. They are firm, irregular, nodular tumors
which do not bleed easily and have little tendency
to ulcerate. ^Microscopically, it presents the same
characteristics as the ordinary types of fibromata.
Neither clinically nor microscopically do they re-
semble, the fibromata of the naso-pharynx just
described.
Carcinomata may arise in polyps or mucosa of
the ethmoids and sphenoids. Several cases have
been reported as having their primary origin in
the mucosa of the turbinate. They are either
squamous cell carcinomata or are composed of
cuboidal cells which occasionally suggest an al-
\eolar arrangement. Sarcomata also spring from
the ethmoidal and sphenoidal region and occa-
sionally from the septum of the nose. ^Malignant
neoplasms of the ethmoidal and sphenoidal re-
gions metastasize freely to the lymph glands of
the neck. Sarcomata in this region, as a rule, are
more destructive than carcinomata, produces
more softening of the bone and of the two are the
more frequent.
Hemangiomata occur on the nasal septum and
tui'binates. It must be remembered that granula-
tion tissue in this region has a tendency to form
many large blood-vessels and even cavernous
sinuses so that many of the so-called hemangio-
mata found in the nose are really not true angio-
mata but inflammatory tissue which has a pe-
culiar appearance. In the pharynx, naso-pharynx
and nasal cavities inflammatory reactions more
closely simulate neoplasms than in any other por-
tion of the body. Very frequently a diagnosis
can only be made with the aid of a microscope
and review of the literature leads one to believe
that even splendidly equipped pathologists make
more mistakes in the diagnosis of tumors of this
region than in any other. iMore and more it
comes to be an accepted fact that the organ in-
volved influences greatly the character of the
new growth and that tumors of various organs
or portions of the body should be studied as
separate entities. There is a great need for more
careful histological study of pathological pro-
cesses of the nose and throat. At present it seems
to be almost a virgin field.
The use of radium in the treatment of these
neoplasms seems to offer the best chance of cure
or relief but the danger of radium has probably
been underestimated. In many cases it is better
to first remove the tumor by surgical methods
and then use the radium as a means of preventing
recurrence. I would like to present several case
histories which I think show the desirability to
this procedure.
Mr. E., age sixty-eight years, presented himself at
the clinic with a carcinoma on the lateral margin of
the tongue as large as a good-sized hickory nut and
was treated with radium. For some time the treat-
ment seemed to be giving most satisfactory results.
At the last treatment he received 600 mgm. hours of
radium and went home to return in four weeks. On
his return half of his tongue was enormously swollen
and there was a large, indurated, ragged ulcer which
bled easily. The patient was in great pain. While
VoL. XII, No. 5]
Journal of Iowa State Medical Society
193
it was appreciated that the radium burn complicated
the picture of malignancy still it was found that the
cancer was progressing and one-half of the tongue
was removed. The entire piece was blocked and
many sections were cut from each block but not a
single cancer cell could be found. The cancer had
apparently been entirely destroyed but the radium
burn had so obscured the picture that it was impossi-
ble to make a correct judgment concerning the state
of the cancerous growth.
Mr. McC., sixty years of age, had been receiving
radium treatment in St. Louis for cancer of the
tongue. The tongue was large and protruded from
his mouth. Two large, foul ulcers were present.
On palpation the tongue had knobby characteristics
and some portions were boardy in consistency but it
was impossible to judge how much of the path-
ological condition was due to the cancer and how
much was due to the radium burn. Xo treatment
was given him.
Mr. \V., age fifty-seven years, came for treat-
ment for cancer of the external ear. He had re-
cently been treated with radium. The external ear
was gone and around the external auditory meatus
was a deep, irregular ulcer about 8 cm. in diameter.
The bone was uncovered in some areas, and near the
auditory meatus it had sloughed away so that it was
obvious that the process had invaded the middle ear
and the mastoid cells. The amount of secondary
infection present was such that the patient’s life was
endangered from meningitis or infected lateral sinus
or other complication. An extensive operation was
done in w’hich all the diseased tissue was removed.
At the time of the operation the dura was found to
be uncovered in the region of the squamous portion
of the temporal bone over a region as large as a
half dollar. The mastoid cells were diseased and the
wall of the Eustachian tube was necrotic so that the
intercarotid artery was exposed.
-\11 the tissue removed was blocked into ten blocks
and numerous sections cut from each block were
examined for malignancj- but no cancer cells could
be found in any part of the tissue.
Histologically, the tissues from both these cases
resembled each other in that both showed a marked
cedema and mj-xomatous and hyaline degeneration
of the tissue. There was also considerable round cell
infiltration. In the tissue from the ear there was also
much granulation tissue which was no doubt the re-
sult of the secondary infection.
NEEDS OF ARMY MEDICAL DEPARTMENT
.\n effort will be started by the medical depart-
ment of the army, headed by Surgeon-General Ire-
land, to induce congress to remedy the existing
shortage of both officers and men, so that the pre-
scribed functions of the Medical Corps may be car-
ried on. This situation is due to the recent reduc-
tion in the army through legislation and the prevail-
ing sliding scale basis of computing the size of the
Medical Corps in ratio to the actual strength of the
entire army. -A. computation submitted to congress
of the needs of the medical department, irrespective
of the present or further reduction in the army, and
also to assure the efficient discharge of its duties and
meet its obligations to its military mission, claims
that the following personnel will be necessary as a
minimum: medical officers, 1,425; dental officers,
295; veterinary officers, 300; administrative officers,
140; enlisted personnel, 13,000. The surgeon-general
in this request for legislation also states that the
Army Medical School and the Medical Field Service
School are operating under a very serious handicap,
although they are the most important agencies for
the instruction of the medical department personnel
of the regular army, national guard and organized
reserve. He insists that the Carlisle school has
barely sufficient men for the up-keep of the station
and that few troops are available for demonstrative
purposes. It is also asked that legislation be enacted
to prevent the deterioration of the Army Nurses’
Corps, and that the grade of student nurse be cre-
ated so that these student nurses may be employed
in army hospitals, and during their period of training
be permitted to perform work which otherwise would
have to be carried on by graduate nurses. Because
of the attractive remuneration and other features
enjoyed by graduate nurses in civil life, the medical
department asserts, it is becoming more and more
difficult to maintain the nurses’ corps of the army.
.All of the legislation proposed by Suregon-General
Ireland has been approved by the war department
and will be taken up by congress in its legislation
for the army during the coming year. — Journal of
A. M. A.
NEW ORGANISM AKIN TO BOTULINUS
The existence, says the Public Health Service, in
a recent report by Ida A. Bengtson has been demon-
strated of an anaerobic organism producing a solu-
ble toxin which affects animals in a manner similar
to that of the botulism organism but which fails to
be neutralized by polyvalent botulinus antitoxin.
Study of the organism, as found in the larvje of the
green fly Lucilia Csesar sent to the service, indicate
that it differs markedh^ from the botulinus isolated
in the United States, and possibly is more nearly
related to the European type described by von Er-
mengem in 1912, though it differs from this in im-
portant respects. Tests on laboratory animals by
inoculation and by feeding caused death in from five
to seventy-one hours. The most striking patholog-
ical results was, as in botulism, the congestion of
the blood-vessels of the brain and meninges. Ef-
forts are being made to produce an antitoxin. The
suggestion that the organism of the disease causes
limberneck in chickens has not yet been demon-
strated.
194
Journal of Iowa State Medical Society
[May, 1922
®l)c Journal of tljc
3otaa ^tatc jHetiical ^ottetp
D. S. Fairchild, Editor Clinton, Iowa
Publication Committee
D. S. Fairchild Clinton, Iowa
\\ . L. Bierring Des Moines. Iowa
C. P. Howard Iowa City, Iowa
Trustees
J. W. CoKExowER Des Moines, Iowa
T. E. Powers Clarinda, Iowa
W. B. Small Waterloo, Iowa
SUBSCRIPTION $2.75 PER YEAR
Books for review and societj- notes, to Dr. D. S.
Fairchild, Clinton. All applications and contracts
for advertising to Dr. T. B. Throckmorton, Des
Moines.
Office of Pvblic.ation, Des Moines, Iowa
Vol. XII May 15, 1922 No. 5
SOME DISSATISFACTION WITH NATIONAL
HEALTH INSURANCE IN ENGLAND
In following the periodical press it is easily
found that the feeling of unrest and dissatisfac-
tion is not confined to business, industry, labor
or the farmer, but extends to the medical profes-
sion as well ; all seem to be influenced by the
thought that each interest is not getting enough
money out of the business, and with but little
thought of service to the public or what is fair or
right. In England before the passage of the
Lloyd George bill, the Friendly Societies carried
the risk and paid the doctor on a contract basis
which M'as unsatisfactory to the doctors, and led
to much poor sendee, and dissatisfaction to the
public. To remedy this the government took over
the function of the Friendly Societies, supervised
the service, and paid much better fees. This an-
gered the societies which had under the old reg-
ulations bought physicans’ services at wholesale
and retailed them to their members. Lender the
new regulations, the societies continued the ad-
ministration of the government insurance but
complained that they did not receive satisfactory
amounts and accused the doctors of poor work.
“The president of the Friendly Societies said that
they were not getting value for the enormous
sums paid to the medical profession. Xo one was
satisfied unless it was the doctors with the pres-
ent system.” The doctors claim that too much
money was paid for administration and not
enough for medical services.
This has brought the whole question under dis-
cussion. XM one appears to be satisfied. Each
believing he does not get enough money as his
share. The Lancet belie^•es that a revision will
be made and that the insurance will be advanced,
not abolished.
The same contention goes on in America, dif-
fering only in the difference between English and
American methods of practice. It is plain that
whether in Europe or America, the medical pro-
fession must watch and guard its interests.
PHYSICAL CENSUS OF THE MALE
POPULATION
The British Government has issued an inter-
esting volume on the physical condition of the
men of England, Scotland and Wales as de-
tennined by examinations for war service. The
results are not flattering. After setting forth the
standards of acceptance for service, a large bodv
of statistics are taken from different sections of
the country with the view of ascertaining what
influence environments and ways of living ma}'
have on physical development.
The examinations were carried out by medical
officers of the regular forces, the special reserve
and territorial forces and by civilian practitioners
specially appointed for the purpose.
From these statistics the British Aledical Jour-
nal expresses much anxiety for the future of
British manhood, “As the result of nearly 2,500,-
000 examinations, less than 872,000 men were
placed in grade 1 — that is to say, only 36 per
cent attained the full normal standard of health
and strength and were judged capable of endur-
ing physical exertion suitable to their age ; 250,-
000 were judged to be totally and permanently
unfit for any form of military service and were
placed in grade 4.” In addition, the British Med-
ical Journal says, “There were twice as many
lads (of eighteen years) totally and permanently
unfit for any force of military service as there
should have been. If such be the state of physique
amongst our j-ouths, what are we to assume as
to the condition of older men who have had to
undergo the full stress of industrial life.”
The findings of the London boards were par-
ticularly bad and the east end of London was
designated as the “Black List.” These are com-
prised of IMile End, Whiteclaped, Stepney, Lon-
don Docks, Bethnal Green and Bow. The occu-
pations included, barbers, Turkish bath attend-
ants, manicurists and complexion specialists.
In the northwestern region conditions were not
much better; underweight was an important fac-
VoL. XII, No. 5]
Journal of Iowa State Medical Society
195
tor, out of 1000 recruits of eighteen years there
were 451 (or 42 per cent) less than 112 pounds
in ^veight. The west midland region, Yorkshire
and east midland region did not differ materially:
In the latter region, tuberculosis was found very
prevalent among the Jews.
In Scotland and Wales, the physical condition
of the men was much better because of the larger
country contingent.
In England and Wales, the bad physical condi-
tion of the young men including sickness and un-
derweight was found on an analysis of the fig-
ures to be influenced largely by the condition of
industrial workers, as bad housing, poor food,
long hours of work, bad sanitary surroundings
and heavy work at an early age. It was believed
that physical conditions of young men could be
greatly improv'ed by better living, better housing
and shorter hours of work for boys and more
recreation. All the areas in England were in-
dustrial, but there were enough country spots to
show the difference between the workers in in-
dustries and mines and the agricultural popula-
tion.
X’otwithstanding the better physical condition
of recruits from Scotland and Wales there was
enough evidence presented by these statistics to
cause Great Britain much anxiety for the future
and to arouse public sentiment towards better
conditions of labor and of living.
We are constantly reminded that under our
form of government, acts of legislatures and the
decision of the courts are apparently not friendly
to the advancement of medicine, at least from our
point of view. We are afflicted by a class of
practitioners who have one thing in mind and
that is money, unfortunately we have some of the
same kind in our own ranks. In 1917, Illinois
passed a medical bill which seemed fair to all
cjualified practitioners but tended to bar unquali-
fied practitioners whose only object w*as to secure
money from the ignorant. But when this law
was tested in the courts on constitutional
grounds, it was easily found that there was the
fatal objection of “discrimination” which will
probably be found in all legislation which at-
tempts to fix an educational qualification.
As it appears to us, our chief effort should be
to maintain as high a standard of education as is
consistent with the interests of the profession and
the public and wholly disregard the irresponsible
imposters in medicine who have always preyed
upon the people and always will irrespective of
laws. The real doctors of medicine have nothing
to fear in their efforts to render service, and tJ
secure legislation for the health and welfare of
the people. We shall loose nothing and will gain
much by forgetting these parasites.
We are frequently reminded by Iowa news-
papers of the greatness of Iowa, the intelligence
of its people, its prosperity; its forward vision
and of the many things that should make the
state a desirable place to live in. Not so much
is said of its roads, or its legislature, but as the
legislators are elected by the people, the people
are responsible for them, and it may fairly be as-
sumed that the legislators reflect the intelligence
of the people. Our neighbor^ the Indiana State
Medical Association Journal says something
about us which is worth reading. Unfortunately
it is too near the truth.
The report of the Committee on Public Policy and
Legislation of the Iowa State Medical Society con-
tains a commentary on the cheapness with which
life and health in Iowa is held in the following:
“The advocates of better health laws have con-
sidered that human life is of more importance than
the lives of farm animals, and asked the legislature
for pure milk for the children, and the request was
turned down, but, when it was demonstrated that
tuberculosis in the herds was killing off the pigs
which drank the same class of milk furnished the
children, then the legislature had no hesitancy in
making an appropriation of $250,000 to clean up the
tuberculosis on the farm, in order to save the life of
the pigs; and the U. S. Government provided another
$250,000, making $500,000 for the two-year period. A
few days later, the same legislature hesitated to ap-
propriate an increase of $5,000 to the board of con-
trol, making a total of $10,000, for an educational
campaign against the ravages of tuberculosis in the
human family.
“In the days of slavery in the South, the colored
people were counted as chattels and worth real
money. If slavery existed today, and it could be
pointed out that the slaves were in danger of being
wiped out,* or their health and working ability was
impaired by disease, it is a safe bet that legislators
would appropriate enough money to protect the
slaves to the fullest possible extent. It seems too
bad that the average legislator cannot be made to
understand that health in human beings is a mone-
tary asset, not only to the individual himself but the
community at large. Therefore, money spent to
stamp out diseases in the human being is well spent,
in fact public health and sanitation is an economic
problem and should be divorced from all ideas of
sentiment. The average legislator trembles with fear
when he thinks of the criticism that will be heaped
upon his luckless head if he fails to promote legisla-
tion that will save 500 hogs from death from hog
cholera, but he never bats an eye, when he is told
that some disease threatens to wipe out of existence
196
Journal of Iowa State Medical Society
.lOCO human beings, and that a little work on his part
may help to avert the disaster. Hogs represent real
tangible dollars, but to the average legislator human
beings have no monetary value. We are under the
impression that most of the work done by our leg-
islators concerning health laws is free from the
economic argument. The thing to do is to put the
matter on the basis of dollars and cents, for that is
the only thing that appeals to the average legislator.’’
PELLAGRA IN THE SOUTHERN STATES
Certain newspapers with small regard for the
truth have made it appear that there exists a
widespread fatal epidemic of pellagra over the
southern states. What motive these papers could
have in publishing such damaging reports it is
difficult to understand. If these statements were
true, it might be assumed that the motive was to
warn people against visiting these infected re-
gions. We have no less authority than Dr. Searle
Harris, editor and secretary of the Southern
Medical Association and Dr. Claude A. Thomp-
son, editor of the Oklahoma State iMedical Asso-
ciation who deny these newspaper statements ab-
solutely and state that there are less than 10,000
cases of pellagra in a population of 35,000,000
people. It is to be regretted that the public press
have so little regard for truth and fairness.
MEDICINE AND POLITICS
Dr. C. S. Pettus in his oration on the History of
Medicine, read before the Arkansas Aledical Society,
among other historical observations, notes the fol-
lowing early participation of politics in official medi-
cine.
“One of the most disastrous impediments to mod-
ern day progression of scientific medicine is politics.
The first noteworthy record of this curse recorded
in America was in 1775, in which year John Morgan
was appointed by congress director general and phy-
sician-in-chief of the American Army. On accepting
his commission he insisted upon rigorous examina-
tions for medical officers and upon subordinating
the regimental surgeons to the hospital chiefs; but
the enmity of his subaltern and the shiftiness of
politicians led to his unjust dismissal by congress in
1777 and the appointment of Shippen in his place.
Morgan made a public statement ably defending
himself with all loyaltj' to the cause and his great
chief, demanding at the same time a court of inquiry.
He was so impressive in his statement that he was
granted this request. After an investigation and two
years of deliberation the court honorably acquitted
bim of all charges; but from this ordeal he was left
poor and broken in spirit.” — Journal of the Arkansas
Medical Society, August, 1921.
[May, 1922
IOWA STATE UNIVERSITY NEWS NOTES
Don AI. Griswold, M.D.
■ Dr. C. W. Chase has been making a thorough can-
vass of the state in the interests of the training
school for nurses at the University Hospital. Dr.
Chase is meeting many young women who are in-
terested in the subject of nursing and giving them
full information and details regarding nursing as a
career.
Dr. and i\Irs. Howard Beye are the proud parents
of a baby girl. Dr. Beye is assistant professor of
surgerj' in the college of medicine and is acting as
head of the department during the absence of Dr.
Row'an.
Dr. L. W. Dean, dean of the college of medicine,
read a paper before the American College of Sur-
geons at Lincoln, Nebraska. The title of the paper
was Focal Infections of the Nose, Naso-pharynx and
Oral Pharynx in Infants and young Children.’’
Dr. Henry Albert, professor of bacteriology and
patholog}', has resigned. About a year ago. Dr. Al-
bert’s health became such that it necessitated his
removing to southern California where he has re-
mained since that time. It was expected that a year
in southern California wouj^d completely restore his
health, but he now writes asking to be relieved of
his University duties, and will probably make his
permanent home in the West.
A new building has been built beside the Univer-
sity Hospital to serve as the urological clinic. This
building has facilities for twenty-four male and
twenty-four female patients with separate clinical
and hospital facilities. There are separate treatment
rooms and all the modern appurtenances of a well
equipped urological clinic. It is connected with the
Universitj' Hospital by a bridge facilitating the
passage from one building to the other. Patients
can be entered at this clinic by the usual procedure
through the Perkins law or by special arrangements
under the venereal disease law.
The following nominations for internes at the Uni-
versity Hospital have been made for the ensuing
year:
(a) Department, ophthalmology, oto-laryngology
and oral surgery: H. F. Hosford, Burlington; Dean
Lierle, Iowa City; W. A. AIcNichols, Osceola; V. K.
Hart, University of Pennsylvania; F. P. Quinn, ex-
terne, Pomeroy. Internes in the department of
ophthalmology, oto-laryngology and oral surgery are
required to have had one year’s hospital experience
in some other department of the hospital before they
are eligible to appointments in this service.
(b) Department of surgery: Lawrence A. Block.
Davenport; John J. Collins, Williamsburg; Paul N.
^lutchman, Bellevue; Harold G. King, Boise, Idaho.
VOL.XII, No. 5]
Journal of Iowa State Medical Society
197
(c) Department of theory and practice pf medi-
cine; Glen W. Adams, Iowa City; David V. Con-
well, Iowa City; John C. Sharder, Iowa City; Ernest
F. Wahl, Wellman.
(d) Department of gynecology and obstetrics;
Glen N. Rotton, Esse-x; Frank G. \’aliquette, Sioux
City.
(e) Department of pediatrics; Moran Foster,
Wellman; Oral Thorburn, Webster; Arnold Smythe,
Scranton.
Interneships are still open and nominations for
appointments will be made soon in the following
services; Department of orthopedics, department of
genito-urinary surgery, department of psychiatry,
department of dietetics, department of anesthetics.
Dr, Tames E. Russell, Jr., who is finishing his sec-
ond year of postgraduate work at the Children’s
Hospital, has joined the Physicians' Clinic of North
Central Iowa, at Fort Dodge. .At^his clinic Di.
Russell will have the advantage of a new well
equipped hospital and will confine his practice to
pediatrics.
Dr. C. P. Howard attended the fiftieth anniversary
of the arrival of Dr. A. E. Crouse in Grundy Cente;-.
The Mid-Winter Conference conducted by the
American ^iledical Association in Chicago was at-
tended by President W. A. Jessup of the State Uni-
versity and Dr. C. P. Howard, professor of theory
and practice, Dr. J. T. McClintock, professor of
physiology, and Dr. Don IM. Griswold, professor of
hygiene and preventive medicine. .All these men
were on the program and presented to the confer-
ence various phases of medical education, as it is
being carried out in Iowa.
The laboratory for the State Board of Health re-
ports having made examinations for rabies on one
horse head, two cow heads, and twelve dog heads,
during the past month. Attention is called to the
fact that rabies is not more prevalent in the summer
months than in the winter and the usual precau-
tions should be taken to guard against rabies re-
gardless of the time of year.
HOSPITAL STANDARDIZATION FROM THE
VIEWPOINT OF THE HOSPITAL
SUPERINTENDENT
Modern hospital administration has become a spe-
cialized profession within the past twenty years.
Hospital administration today is not only a science,
but a business. Those of us who have been hospital
administrators for years realize that we are only at
the beginning. Our hospitals stand for two pur-
poses; they teach and they heal. It is not possible in
every community that every hospital be a teaching
hospital, but each one must be a healing hospital.
If we hospital administrators are going to take our
place in the community without a pretense, when we
go out to financial men for aid, we must be in a po-
sition to show them the result of our work in black
and white. We must prove by results that we are
entitled to public confidence and support.
This procedure places a certain increase in ex-
penditure on the hospital administrator. There was
a time when we were quite content with a writte;i
report of an operation. But now we are not content
with that. TJie majority of the reports are not legi-
ble. We must have a typewritten report. Tha'
means an extra stenographer and typewriter and
extra equipment, and I can assure you that anything
done to get 100 per cent of hospital standardization,
as we have tried to do it, has meant increased ex-
penditure to the hospital. But I can assure you, in
addition to that, it has given us 500 per cent increase
in results. -A record for which we spent a thousand
dollars a year was not worth 10 cents when five
years went bj-, and we couldn’t use it. Certainh' the
money we spent on records heretofore was abso-
lutely useless. Now, we can get our records at
an\’ time and the}' are logical and contain every de-
tail. We are considering putting in additional equip-
ment and when the time comes that one of our sur-
geons seeks information we hope he may make use
of it.
Records — How Long Shall We Keep Them?
This brings up the question, “How long shall we
keep our records?’’ That has bothered a great many
of the administrators of our hospitals. A'ou cannot
admit seven or ten thousand patients a year and keep
a full record of all of them and expect to be able to
house such records with the quarters that are avail-
able.
If our records are to be of the use they are ex-
pected to be, we cannot turn the patient out of the
hospital without a very beautifully kept history. We
turn our patient adrift as cured without the further
knowledge at some late date whether or not the
time and money spent on the cure of the patient will
be lost. That consequently brings up the follow-up
system. It is almost impossible for us to know that
a patient has had proper treatment unless we use the
follow-up system. And to conduct a follow-up sys-
tem properly costs a great deal of money. As a rule
that does not matter to the >urgeon and to the at-
tending men of the hospital.
The more a hospital administrator understands the
difficulties of his attending staff, the more willing
will he be to provide the staff with material or
equipment to meet the hospital standard or for any
other purpose that might be necessary. For that rea-
son hospital standardization has indirectly brought
the attending staff and the hospital administration
much closer together.
Staff Meetings
I think it has been conclusively proved that staff
meetings properly run can be of immense benefit
to the patient — to the patient first, because that is
198
Journal of Iowa State Medical Society
[May, 1922
the ultimate object of our hospitals — and to the at-
tending staff, second. How staff meetings are to be
run is a question of opinion. One hospital superin-
tendent says it is best to serve luncheon in conjunc-
tion with the meeting. When this is done fewer
members leave the meeting for they hear things dis-
cussed with less loss of time. I have tried that plan
myself and I find it has worked out wonderfully
well.
If staff meetings are advantageous from the stand’
point of our hospital administrators — and I am sure
they are — and if staff meetings are a good thing for
the attending staff and a success, why not let us
have staff meetings for the rest of the hospital, for
the matron of the training school, for the chief en-
gineer, the housekeeper, the fireman? Why not
have them meet and hear one another’s troubles?
They are all spokes of the same wheel, and I am
convinced that the results of such meetings would
be 100 per cent beneficial. There is no reason why
the chief engineer, for instance, should not know
something about what is going on in the hospital.
If such meetings are held, you will find that you
have a spirit of cooperation among the workers,
they work together, not against one another — a con-
dition we used to see so often.
Autopsies
Hospital administrators are anxious to have as
many autopsies done in the hospital as possible. I
think it is safe to say that the hospital administrator
takes more personal interest in the securing of these
autopsies in very many cases than the attending
man.
Consent for postmortem examination can be se-
cured, and I have been waiting for many a long day
to have this opportunity to tell you just what we
have been doing in the Montreal General Hospital. I
am not doing it myself. I have nothing to do with
it, but a member of my administrative staff has.
Last year we secured permission for postmortem
examination in 86 per cent of all deaths in the hos-
pital, and this year to date we have secured permis-
sion in 87 per cent.
Hospital standardization brings to the adminis-
trator of the open hospital — I am speaking on
behalf of or against open hospitals — a controlling
weapon over his attending staff. It does not neces-
sarily need to be used as a weapon. But this much
we do know that in open hospitals the work has not
been of the same caliber as the work done in closed
hospitals. The hospital administrator today in the
open hospitals has in his hands with the aid of his
committee of management a means, we will not call
it a weapon, whereby he can come before his attend-
ing staff and tell them that they must meet the con-
ditions contained in the minimum standard. He can
say to them: “Yes, we will give you an open hos-
pital, but in order to derive any benefit from this
open hospital, you must meet our minimum stand-
ard.”— Alfred K. Haywood, M. D., Montreal, Super-
intendent, Montreal General Hospital; Representing
Canada for the American Hospital Association.
FIELD SECRETARY
Announcement was made that Dr. Olin West had
been offered and had accepted the position of field
secretary, American Medical Association. Dr. West
is secretary of the Tennessee State Medical Associa-
tion, and executive secretary of the Tennessee State
Board of Health. It was understood that Dr. West
would be able to so adjust his affairs in Tennessee
that he could report for duty on February 15. Later,
however, it was found that he could not conscien-
tiously give up his responsibilities to his state asso-
ciation and to the state board of health before the
middle of April, when he will report for permanent
duty in Chicago. — Tournal of A. kl. A., February 18,
1922.
ELECTION OF EDITORS OF SPECIAL JOUR-
The following editors were elected as members of
the editorial boards of the several special journals.
Dr. W. T. Longcope, New York City, Archives of
Internal ^ledicine.
Dr. William McKim Marriot, St. Louis, American
Tournal of Diseases of Children.
Dr. Hugh T. Patrick, Chicago, Archives of Neu-
rology and Psychiatry.
Dr. M. B. Hartzell, Philadelphia, Archives of Der-
matology and Syphilology.
Dr. Evarts Graham, St. Louis, Archives of Sur-
gery.
Dr. Reid Hunt, Boston; Dr. W. W. Palmer, New
York City, and Prof. Tulius Steiglitz, Chicago, were
reelected members of the Council on Pharmacy and
Chemistry. Dr. George W. Hoover, Bureau of
Chemistry, department of agriculture, Chicago, was
elected to fill the vacancy created by the resignation
of Dr. C. L. Alsberg.
L'pon nomination of the several councils, Drs. N.
P. Colwell and Frederick R. Green were relected,
respectively, secretary of the Council on Medical
Education and Hospitals, and secretary of the Coun-
cil on Health and Public Instruction. — Tournal of
A. M. A., February 1*8, 1922.
Dr. Harlow Brooks in The Journal of Laboratory
and Clinical Medicine, describes a method employed
by Dr. David Dennis of Erie, Pennsylvania, to de-
termine early arterial disease, which is a matter of
considerable importance.
Study of the vessels is accomplished by the use of
two very simple and easily manipulated instruments,
which are usually in the pocket of the average prac-
titioner. The ordinarj^ pocket electric flashlight of
which the most convenient for this purpose is the
“fountain pen” type is used for illumination. The
patient is directed to turn his eyes either the one
side or the other, and the light held at a distance of
about three to four c.m. is directed obliquely on to
the ocular conjunctiva. Study of the vessels is
then made through an ordinary ophthalmologist’s
VoL. XII, No. 5]
Journal of Iowa State Medical Society
199
loupe, which is the most adaptable to the purpose,
though other lenses are also fairly satisfactory. The
loupe I's held at the proper focal distance and for
most satisfactory study the eye of observer is
brought close to the lens, just as in the use of the
microscope. The vessels under study in the various
levels of the membrane are brought sharply into
focus by moving the lens to and fro and for the
purpose of steadying it the fingers of the lens hand
may be rested on the orbital arch of the patient.
The study may be made in the diffuse light of the
examining rooms or even more satisfactorily in the
dark room.
The great advantage to the clinician in the method
is that a sufficient technical skill may be acquired
with a few days’ practice. It demands no special
instruments and less time is required for the intimate
study of the minute circulatory changes in the cere-
bral vessels than is necessary for a reasonably care-
ful palpation of the radial, brachial or temporal
arteries.
QUESTION OF DAMAGES INVOLVED IN
FAILURE TO USE X-RAY IN FRACTURE
OF FEMUR
(From the British Courts)
Mr. R. C. Elmslie, orthopedic surgeon to St. Bar-
tholomew's Hospital, who operated on the patient,
calls attention to the great medicolegal importance
of the case. The result of the trial largely depended
on the question whether refracture had occurred.
He was asked whether he had found evidence of re-
fracture. He replied that he had not, but he pointed
out that the interval of eighteen days between the
giving way of the limb and the operation was suffi-
cient for signs of refracture to have disappeared.
Apart from this, both judge and jury seem to have
ignored the possibility of callus bending, a common
incident in fracture of the femur. Mr. Elmslie re-
gards as important lessons to be learned from this
case: Every case of fracture should be treated as a
possible medicolegal one. Careful notes should be
made at the time. If a roentgenogram is not taken,
the reason should be stated in writing. Physicians
should not commit themselves to statements as to
the nature of the injury without roentgen-ray evi-
dence. Apart from this, the medical profession
must feel considerable perturbation at a legal deci-
sion which appears to place on them responsibility
for the result of their treatment, apart from their
acknowledged responsibility to use recognized meth-
ods, for the mere result that the treatment was un-
successful was accepted as a sufficient cause for ac-
tion. The loss in damages and costs sustained by
the physician amounted to more than $8000. The
view widelj" taken in the profession is that the ver-
dict was a miscarriage of justice. A subscription list
has been opened to reimburse the physician. The
movement is supported by leading surgeons includ-
ing Sir Robert Jones, Sir John Lynn-Thomas, Sir
Hamilton Ballance, Mr. G. E. Cask and Mr. R. C.
Elmslie. — Journal A. M. A., December 31, 1921.
LABORATORY WORKERS CONTRACT
TULARAEMIA
All six of the laboratory workers of the U. S. Pub
lie Health Service who have been studying tul-
araemia, a disabling sickness of man which has been
known, particularly in Utah, for the last five years,
have contracted the disease, two of them being in-
fected in the laboratory in L'tah and the other four
in the hygienic laboratory in Washington. Such a
record of morbidity among investigators of a disease
is probably unique in the history of experimental
medicine.
Two of these workers are physicians; one is a
highly trained scientist; and the others are experi-
enced laboratory assistants. One of them contracted
the disease twice, once in the laboratory in Utah and
again, two years and five months later, in the labor-
atory in Washington.
In these workers the disease began with a high
fever, lasting about three weeks, and was followed
by two months of convalescence. The disease has
few fatalities, its chief interest arising from the long
period of illness which it causes in mid-summer,
when the farmers of Utah are busily engaged in cut-
ting alfalfa and plowing sugar beets.
The studies into the cause and transmission of the
disease show it to be due to a germ, bacterium
tularense, which is conveyed by six different insects:
the blood-sucking fly, chrysops distalis; the stable
fly, stomyox calcitrans; the bedbug, cimex lec-
tularius; the squirrel flea, ceratophyllus acutus; the
rabbit louse, hsemodipsus ventricosus; and the mouse
louse, polyplax serratus. Only the first four of
these are known to bite man. It appears possible
that the germ may also enter through unbroken skin;
for instance, that of the hands.
THE RETREAT
On account of the scarcity of money in Iowa at
the present time the cost of treatment at “The Re-
treat,” Des Moines, for the first month has bee.i
reduced from $200 to $150. We are treating patients
more successfully than ever before. It is still a
clearing house in which to study and to diagnosticate
cases. This is a place to cure acute and promising
cases. The facilities for classification are good, and
the equipment is excellent. The employes are suit-
able, and deeply interested in this kind of work.
They co-operate in various ways to entertain, to
encourage, and to strengthen the patients. A united
endeavor is made to restore patients to a normal
condition as speedily as possible.
Fraternally yours,
Gershom H. Hill.
200
Journal of Iowa State I^Iedical Society
[May, 1922
THE TREATMENT OF CARBON MONOXIDE
POISONING
Carbon monoxide poisoning is one of the most
widely distributed and most frequent of industrial
accidents, says the U. S. Public Health Service. The
gas is without color, odor, or taste. It is an ever-
present danger about blast and coke furnaces and
foundries. It may be found in a building having a
leaky furnace or chimney or a gas stove without flue
connection, such as a tenement, tailor shop, or
boarding house. The exhaust gases of gasoline au-
tomobiles contain from 4 to 12 per cent of carbon
monoxide, and in closed garages men are not infre-
quently found dead beside a running motor. A
similar danger may arise from gasoline engines in
launches. The gas is formed also in stoke-rooms, in
gun turrets on battleships, in petroleum refineries,
and in the Leblanc soda process in cement and brick
plants. In underground work it may appear as the
result of shot firing, mine explosions, or mine fires,
or in tunnels from automobile exhausts or from coal
or oil burning locomotives.
Carbon monoxide exerts its extremely dangerous
action on the body by displacing oxygen from its
combination with hemoglobin, the coloring matter
of the blood which normally absorbs oxygen from
the air in the lungs and delivers it to the different
tissues of the body.
Oxygen will replace carbon monoxide in combin-
ation with hemoglobin whenever the proportion of
oxygen in the lungs is overwhelmingly greater.
Therefore:
1. Administer oxygen as quickly as possible, and
in as pure form as is obtainable, preferably from a
cylinder of oxj-gen through an inhaler mask.
2. Remove patient from atmosphere containing
carbon monoxide.
3. If breathing is feeble, at once start artificial
respiration by the prone posture method.
4. Keep the victim flat, quiet, and warm.
5. Afterwards give plenty of rest.
MEDICAL NEWS NOTES
.\ction to remedy conditions of health in Des
Moines, revealed by F. J. Alber, county registrar of
vital statistics at the first meeting of the city health
council, will be the first step of the newly formed
council.
Meeting Saturday, ^larch 18, in the office of Dr.
H. L. Saylor, city health director, the council took
definite action to bring these conditions before the
attention of the medical profession and the public.
Deaths in Des Moines in the past eight months
have numbered 1,018, Alber reported. Particular at-
tention was called to the fact that ninety-eight, or
nearly 10 per cent of these were still births. Seventy
babies died before reaching the age of one month,
and 109, exclusive of still births, before reaching one
Information in regard to causes of this high in-
fant death rate investigated by Dr. Wilbur Conkling,
Dr. Rodney Fagan and F. J. Alber, will be highly
educational to the people of Des Moines.
The city health council, upon recommendation of
the secretary of the state department of health, ap-
pointed as a special committee on public health edu-
cation Dr. Rodney Fagan, secretary of the state
board of health; P. B. Sherriff, chairman of the Polk
County Hospital Board, and Miss Adah Hershey,
superintendent of the Public Health Nursing Asso-
ciation.
The ^ledical Association of Cherokee County has
agreed to attend to all the medical and surgical
needs of the poor of the county until January 1, 1923,
and to protect the county agents against any claim
for damages that may be made by any dissatisfied
members for the sum of $3,500. Any regular prac-
titioner, whether a member of the association or not,
is privileged to sign the agreement. Sick persons
will be allowed to call the physician of their choice.
In the case of an epidemic in any part of the count3'
the entire medical staff is mobilized to control the
spread of the disease. The arrangement will provide
the best surgical and medical talent of the county
for the poor and will open for their use the equip-
ment of the Sioux Valley Hospital at Cherokee. At
the close of the j'ear, the $3,500 will be distributed
among the physicians in proportion to the work
thej^ have done.
People who have seen and visited Dr. William
Maj'o’s houseboat, the ^Minnesota, which often laid
over in Rock Island on trips up and down the
river, will be interested in the announcement that
Dr. ^lajm is having built at an up-river boatyards a
new palatial houseboat, which will be larger, better
and more beautiful. The new craft of the famous
Alinnesota doctor will be the most elaborate and
most luxurious boat to travel on the river. The
!Mayo home is at Rochester, Alinnesota. The new
boat will probablj" carry the same name as the old
one.
The boat will be 123 feet in length, will have a 24-
foot beam, and will draw thirty inches of water. The
light draft of the boat will enable it to operate in
shallow waters. Twin eight cylinder marine gas en-
gines will give it the speed of the average river
steamer.
The' boat will be ready for launching about Alay 1,
with all of the latest devices for heating, lighting,
plumbing and cooking installed and readj' for use.
Accommodations for carrying automobiles will be
had on the boat and will be made for the quick load-
ing and unloading of the machines. The boat will
probably cruise to all of the important midwestern
racing regattas and cruising pageants during the sea-
son 1922. — Davenport Times.
vear.
\'0L. XII, Xo. 5]
Journal of Iowa State ^Medical Society
201
A new suit, after the old was dismissed, was filed
by Dr. T. \V. Rowntree against the Automobile In-
surance Company, Hartford, Connecticut, on policy
to recover $6,000 insurance on radium owned by the
Doctor, which mysteriously disappeared while being
used to treat a patient October 25, 1921.
The petition states that plaintiff understands the
defendant is resisting payment on the following par;
agraph in the policy; “Xo claim to attach hereto
for loss while any radium insured hereunder is used
on or about patients unless, at the time of loss, they
are being treated under the exclusive care of a reg-
istered nurse, hospital nurse, a medical doctor or his
assistant.”
It is explained that at the time the radium disai>-
peared it was being used on a patient recommended
by a regular graduate physician for treatment b>
plaintiff, and that the case was in general charge of
the head nurse on the floor of the hospital where the
patient was being cared for. The radium was to re-
main on the patient for eight hours and the plaintiff
says he told the nurse to notify him at the end of
that time. Before the eight hours had elapsed, how-
ever, the nurse telephoned that the radium could not
be found.
The Dubuque County ^Medical Society and the
County Board of Supervisors have entered into an
agreement whereby the medical men of Dubuque
county agree to render medical aid to the indigent
poor of Dubuque countj' for a year at the stipulated
price of $3,250.
The doctors are agreed to each serve the county
for a period of ten days — during which times they
attend all persons who are county charges free to
the individual. This service only applies to the in-
digent poor of Dubuque county.
It should be stated also that the specialists of the
city are alloted specific times when they are sub-
ject to call for the care of indigent poor.
By this method the worthy poor are given the
best medical treatment obtainable in Dubuque
county. For instance: in case of a specific surgical
operation on the eye — the poor person has the bene-
fit of a skilled operator or specialist.
In case of necessity, there must be consultations
had, then again the indigent poor gets the best skill
there is in our county.
SOCIETY PROCEEDINGS
Cerro Gordo County Medical Society
Meeting of the Cerro Gordo County Medical So-
ciety held in the Chamber of Commerce rooms, ^ila-
son City, Iowa, February 28, 1922.
fleeting called to order by Vice-President Dr.
Hubbard. Seventeen members were present.
Autopsy reports of two cases previously shown
were given by Dr. G. M. Crabb.
The scheduled program for the evening was given,
consisting of: The Anatomy of the Perineum, Dr.
Raymond Weston. The I’erineum from the Clini-
cian’s Standpoint, Dr. C. F. Starr. The I’erineum
from the Surgical Standpoint, Dr. G. M. Crabb. Th '
Perineum from the Genito-Urinary Standpoint, Dr.
X. C. Stam.
Discussion was opened by Dr. C. 51. Franchere,
followed by Drs. Starr and C. P. Smith and discus-
sion closed by Dr. Weston.
Wilbur L. Diven, Sec’y.
Cerro Gordo County Medical Society
Twenty members of the Cerro Gordo County 5Ied-
ical Society and four visiting physicians were present
at the monthly meeting of the Cerro Gordo County
Medical Society which was held at 5Iercy Hospital,
Mason City, Iowa, Tuesday evening, April 25.
After a short business meeting the meeting was
turned over to Dr. J. T. Strawn of Des 5Ioines,
Iowa, who gave a talk and lantern slide demonstra-
tion on the subject. X-ray Diagnosis in Gastric Le-
sions. Discussion was opened by Dr. C. E. Dakin.
Following the program the Sisters of the Hospital
served light refreshments to the physicians present
and a short social session concluded the meeting.
W. L. Diven, Secretary.
Kossuth County Medical Society
The Kossuth County 5Iedical Society held a reg-
ular monthly meeting in Bancroft and had an un
usually large attendance. The meeting was held in
the Woodman hall. The following members and
visitors were present: Cretzmeyer, Hartman, Fel-
lows, AVallace and Kenefick of Algona, Smith of
Britt, Janse of LuVerne, Filmore of Corwith, Peters
and Clapsaddle of Burt, Sartor of Titonka and De-
vine and 5Iaher of Bancroft.
Story County Medical Society
Si.xteen doctors of the Story County 5Iedical So-
ciety were present at a dinner served at the Sheldon-
Munn Hotel 5Iarch 9 at 6:30.
Among the out of town doctors present w'ere Dr.
Houston of Nevada; Dr. P. Joor of 5Iaxwell; Dr.
5IcBryde, a government research worker, and Dr.
F. H. Connor, of Nevada.
During the meeting Dr. Budge talked on Acidosis,
followed by a talk. War Gas and its Effects Upon
the Human Body, given by Dr. E. B. Bush. Dr.
Connor of Nevada presented an abstract of a patient,
giving the history and treatment of a complicated
case, finally resulting in death.
The next regular meeting of the society will be
held in X'evada April 21, on which date a tuberculosis
clinic will also be held. A similar clinic, given un-
der the auspices of the Red Cross and Story County
Medical Society, will be held in Ames, April 14.
Taylor County Medical Society
■At the meeting of the Taylor Count}' Aledical So-
ciety, Alarch 21, 1922, the following resolution was
202
Journal of Iowa State Medical Society
[May, 1922
passed. Whereas the Public and Profession are be-
ing sold out to —
(1) Foundation control of “full time” medical
education.
(2) Lay board domination and the “closed shop”
hospital.
. (3) Specialized state medicine, subsidized com-
munity health centers and hospitals under political
or university control.
(4) Legislative dictation of therapy and fees.
(5) Demoralization of medical standards by the
expansion of cults.
(6) Exploitation of the specialties by lay techni-
cians.
Therefore Be It Resolved, That all the delegates
of the Iowa State Medical Society to the A. M. A.
meeting in St. Louis, Missouri, Maj^ 22-26, 1922, are
hereby instructed to vote for —
(a) A change of policy and leadership in the A.
M. A. pledged to the immediate abolition of the
evils mentioned, and constructive protection of med-
ical interests.
(b) The repeal of multiple representation and
plural voting privilege by section delegates.
(c) The election of trustees for a period of two
years; five trustees to be elected one year, and four
the next, to prevent the trustees from perpetuating
oligarchial rule.
Be it Further Resolved, That copies of these reso-
lutions be sent at once to the official organ of the
Iowa State Medical Society, the Journal of the A.
M. A. and the medical advisory committee.
Passed March 21, 1922.
(Signed) B. H. MILLER, President,
A. E. KING, Secretary.
Webster County Medical Society
At the regular meeting of the Webster County
Commercial Club rooms, a paper was given by Dr.
C. H. Mulroney. Or. Mulroney had for his subject.
New Methods in the Treatment of Fractures.
Shenandoah City Medical Association
An elaborate four course banquet was served at
the Doty Hotel at 6 o’clock March 9 for members of
the City Medical Association, Shenandoah.
During the evening a round table discussion on
Tuberculosis was held. Those present at the ban-
quet were: Dr. T. L. Putman, president; Dr. J. O.
Weaver, Dr. M. O. Brush, Dr. .A. O. Wirsig, Dr. B.
S. Barnes, secretary; Dr. L. L. Baker, Dr. J. F.
Aldrich, and Dr. W. F. Stotler.
HOSPITAL NEWS
Finley Hospital, Dubuque, is demonstrating in an
interesting way what can be done in a standardized
hospital in a comparatively small city. The lab-
oratory of pathology and bacteriology issues a
monthly bulletin. The one before us presents a
study of chemical blood analysis in diabetes and
nephritis, in which it is stated that: “Valuable in-
formation in regard to diagnosis, prognosis and
treatment of diabetes and nephritis may be obtained
by chemical examination of the blood.” Under the
head of diabetes it is shown “that sugar is a normal
constituent of the urine and that the amount may
vary between 0.05 and 0.2 per cent.” In view of this
fact it is readilj" apparent that a definite diagnosis of
diabetes mellitus cannot be made without an exam-
ination of the blood to determine whether or not a
hyperglycemia actually exists. The details as to
determination are presented in considerable details.
In regard to nephritis certain tests are of the first
importance. (1) Blood pressure. (2) Urinary ex-
aminations. (3) Phenolsulphonephthalein excre-
tion. (4) Non-protein nitrogen content of the
blood. (5) Ability to excrete in the urine, added
amounts of salt and urea given through the mouth.
Conclusions — (1) Diabetes cannot be definitely
diagnosed without determination of the blood sugar.
(2) Gluclose tolerance tests are of great value in
differentiating diabetes mellitus and renal diabetes.
(3) Figures representing the H-ion concentration
of the blood and the carbon-dioxide combining
power of the plasma best indicate the severity of
acidosis. (4) From the standpoint of prognosis in
nephritis, estimation of blood creatinine should fur-
nish valuable information. (5) From the stand-
point of diagnosis and treatment of nephritis es-
timations of blood urea nitrogen are most useful. (6)
Blood chemical findings are more dependable for
diagnosis, treatment and prognosis in diabetes and
nephritis, than similar determinations on the urine.
Owing to the large number of patients at the
Lutheran Hospital, Des the fourth and fifth
floors of the new nurses home will be opened to ac-
commodate the increase.
The nurses home which is built out to the west of
the original hospital is to furnish a home for about
seventy nurses and rooms for fifty patients.
The home has been built at a cost of $250,000.
It will be dedicated when the Iowa conference of
the Evangelical Augustana Lutheran Church meets
in April.
The conference will be held the week of April 24
to 30 and the hospital will be dedicated on the last
day and opened as a nurses’ home May 1.
Action was taken by the city council, Ames, at its
regular meeting in the city hall March 20 which will
assure the building of a nurses’ home in connection
with the Mary Greeley Hospital.
Contracts for erection of Allen Memorial Hospital,
Waterloo, and electrical wiring, under modified
plans, were awarded by the board of trustees and
work will begin at once. Register & Buxton, Water-
loo, was given the general contract on a bid of $99,-
994; tile and marble work went to Waterloo Tile &
Marble Co., at $9,199 and electric wiring to Cole &
Sweetman, also of Waterloo, at $4,850.
VoL. XII, No. 51
Journal of Iowa State IMedical Society
203
The Kossuth Hospital will be opened at once, un-
der the management of Mrs. .-X. \V. Isaacson. The
hospital will be open to all physicians in good
standing.
PERSONAL MENTION
Dr. and Mrs. C. F. Wahrer of Fort Madison, Iowa,
have just returned from a two months’ sojourn in
California where they visited their daughter, Mrs.
W. A. Bevan, whose husband. Captain Bevan, is
chief engineer of Rockwell Field, A.S., Coronado,
California, and Dr. Carl W. Wahrer, formerly of Ft.
Madison, and member of the Iowa State Medical
Society, now of Sacramento, California. Dr. Wahrer
returned with increased health and is at it again as
usual and expects to attend the annual session of the
Iowa State Medical Society as usual. Mrs. C. F.
Wahrer had the misfortune to fall a victim to pneu-
monia while at Coronado, which she contracted
while at the Grand Canyon, where it was unusually
cold. This augmented by an unusually cold and
damp California weather, made her illness very se-
vere, from which, however, she was fortunate to
recover.
An honorary birthday dinner was given at the
Osceola Sanitarium March 8 at 7:30 p. m. for Dr.
W. O. Parrish, senior dean of the medical men of
the county. Dr. Parrish observed his eighty-third
birthday. The dinner was arranged by a committee
of three doctors, J. D. Shively, F. W. Sells and C. E.
Lowery. Medical men of Clarke county as well as
others from Decatur county and Warren county
were present as guests. Dr. Parrish was born at
Hanover, Jackson county, Michigan, Alarch 8, 1839.
In 1848 his father, mother, brother and sister moved
to Leslie, Michigan, on a farm. In the summer of
1856 he moved to Pella, Iowa. In 1857 he entered
Central University as a student where he remained
until 1860. Commenced clerking for O. Cole in a
general store. In May he enlisted in Knoxville
county for the Civil War; rendezvoued at Keokuk
and put in Co. B. 3rd Iowa Infantry, was in all the
battles with the regiment, marched with Sherman to
the sea. Returned home in 1865, studied medicine
under Dr. B. F. Keables. Attended medical college
at Keokuk, Iowa. Graduated in 1868. Commenced
practice at Galesburg, Iowa. In 1897 moved to Hope-
ville, Iowa. In 1897 moved to Osceola where he has
spent the remainder of his life.
The Grundy County Medical Society has sent out
invitations to a county meeting and banquet at
Grundy Center on March 15 which is held in honor
of one of the grand men of that county. Dr. Eugene
A. Crouse. The event is in celebration of the com-
pletion by Dr. Crouse of fifty years of service
to the people of the county. Dr. Crouse is a grad-
uate of the medical department of the L’niversity of
Pennsylvania and he came to Grundy county in the
spring of 1872 and has been in active work everj-
since. There is but one physician living today in
this section of Iowa who was practicing at the time
Dr. Crouse began his work in Grundy county and
that man is Dr. J. E. King of Eldora. Dr. Crouse
is not as old a man as his fifty years’ experience
would indicate as he was young when he graduated
from the medical school. He is young in spirit and
still active in practice.
Dr. La \’ine, formerly of Defiance, Iowa, a grad-
uate of Creighton University, Omaha, will take up
the practice of Dr. R. W. Robb of Blanchard.
OBITUARY
Dr. W. A. Cooling died at his home in Wilton,
March 17, 1922.
Dr. Cooling was born in Foster, Ohio, near Cin-
cinnati, June 24, 1872, and came with his parents to
Wilton \t-hen he was less than a year old. He at-
tended the public schools of Wilton, and was grad-
uated from the high school here in the class of 1890,
thereafter attending Northwestern University and
Rush Aledical College of Chicago.
After completing his education, he entered upon
the practice of medicine with his father. Dr. A. A.
Cooling, with whom he continued his practice until
the death of his father in 1900, since which time he
has conducted an office alone.
His wife and one brother, Arthur B. Cooling of
DeKalb, Illinois, survive.
Dr. R. E. Buchanan died at his home in Independ-
ence, March 10, 1922, from heart disease. Dr. Bu-
chanan was an active man in the affairs of his home
city. He continued his professional work up to
March 2, eight days before his death. He was a
member of the Buchanan County Medical Society;
the .\ustin Flint-Cedar Valley iMedical Society, the
Iowa State Medical Society and of the American
Medical Association.
Dr. R. E. Buchanan was born in Portage county,
Ohio, in 1854, the eldest of nine children of Thomas
Beatty and Martha Ray Buchanan. When only a
few months old he was brought by his parents to
Monroe county, Iowa, and lived there until 1872,
when they removed to Turner county. South Dakota
During the next seven years he engaged in black-
smithing at Yankton and at Swan’s Lake, proving up
on a homestead meanwhile. It was in 1879 that he
began reading medicine in the office of Dr. A. I,.
Peterman, a prominent physician of that section.
Four years later, in 1883, he graduated in medicine
from Rush Medical College. He first began prac-
ticing in Parker, South Dakota, served a term as
mayor of that city, and continued there until 1891,
except for a period in 1888, when he acted as superin-
tendent of the insane asylum in Yankton, South Da-
kota. In 1891 he came to Independence and here he
remained actively in the practice of medicine until
his death.
In Parker, South Dakota, December 24, 1883, Dr.
Buchanan was united in marriage with Miss Ella E.
204
Journal of Iowa State Medical Society
Peterman. To them three children were born; Rose,
who resides in the home; Georgie, the wife of Prof.
T. R. Johnson, and who passed away in Momence,
Illinois, September 14, 1914, and Dr. R. A. Buchanan,
a practicing physician in Wessington, South Dakota.
Dr. Buchanan is survived by his mother, who is in
her ninety-second year and lives near Hurley, in
South Dakota; also two sisters and two brothers;
Mrs. Anna Woodward, of Hurley, South Dakota;
Mrs. Emma Jones, of Sioux City; J. R. Buchanan, of
St. Paul, Minnesota; Thomas Buchanan, of Hurley,
South Dakota.
For thirty years Dr. Buchanan was one of the
most prominent physicians and surgeons of this
county, and for fifteen years he maintained his own
private hospital. Dr. Buchanan was a successful
business man as well as a successful doctor. He was
vice-president of the People’s National Bank and
occupied the upper floor of the bank building for his
offices. Dr. Buchanan was devoted to his profes-
sion. His idea of a vacation was to attend clinics
and lectures by the leaders in medical research and
practice, thus fitting himself to be of greater service
to his own patients. He put into actual practice the
old motto, “When there is life there is hope,” and
many owe their lives today to his dogged determin-
ation to fight to the very last.
BOOK REVIEWS
THE PRINCIPLES OF MEDICAL TREAT-
MENT
By George Cheever Shattuck, M.D., A.M.,
Assistant Professor of Tropical Medicine.
Harvard Medical School; Formerly Assist-
ant Physician Massachusetts General Hos-
pital. W. M. Leonard, Inc., Publishers, 1921.
This book consists of outlines of treatment of dif-
ferent forms of disease. In chapter one is presented
Disorders of the Circulatory System, (a) Cardiac
Insufficiency, (b) Valvular Disease, (c) Pulmonary
Edema, (d) Angina Pectoris. The treatment of these
various conditions is offered as the methods em-
ployed at Massachusetts General Hospital under
Professor Shattuck and his associates. Chapter two
considers Nephritis under the classification of six
types of the disease. Chapter three. Acute Infectious
Diseases, (a) Typhoid Fever, (b) Rheumatic Fever.
Chapter four. Acute Infections Most Common in
Childhood. Chapter five. Acute Infections of Res-
piratory Tract. Chapter six. Pulmonary Tuberculo-
sis, by John B. Howes, M.D. Chapter seven. Gastro-
intestinal Disorders, Gastric and Duodenal Ulcer.
Chapter eight, Diabetes Alellitis, by Harrison Ragle,
AI.D. Chapter nine. Medication.
This is the fifth edition of case histories presented
in attractive form with alternate blank pages for
notes. The general practitioner of medicine will
find this book a convenient aid in following an ap-
proved treatment of the common diseases and a sug-
[May, 1922
gestion in case records and notes for private practice
and hospital service.
THE LIFE OF JACOB HENLE
By Victor Robinson, M.D., Editor of Med-
ical Life. Published by Medical Life Com-
pany, 12 Mount Morris Park, West, N. Y.,
1921. Price $3.00.
The older students of anatomy and histology will
recall the name of Dr. Jacob Henle who was in his
day the greatest German histologist. But little was
known of his life and work beyond his histologic and
anatomic researches. Dr. Robinson who has con-
tributed much in the direction of medico-historical
writing has with great industry worked out the
private life of Henle which was full of interesting
experiences.
A brief outline of his work is presented by the
greatest living medical historian, Lieut-Col. Fielding
H. Garrison of the surgeon general’s library.
Dr. Henle was born in the summer of 1809 of
Jewish parents at Furth, near Nuremberg, and died
in 1885. He was one of Johannes Muller’s favorite
pupils, one of his prosectors in Berlin; was profes-
sor of anatomy at Zurich, 1840; at Heidelberg and
Gottingen from 1852 to 1885; discovered the external
sphincter of the bladder, the central chylous vessels,
the internal root-sheath of the hair, the Henle tu-
bules of the kidney and gave the first accurate de-
scription of the histology of the cornea and of the
development of the larynx. These are a few of the
discoveries of this remarkable man. Those who are
interested in the lives of the men who made medi-
cine, will find this book worth reading.
THE SURGICAL CLINICS OF NORTH AMER-
ICA FOR OCTOBER, 1921
W. B. Saunders Company. Price, Paper
$12.00 Net, Cloth $16.00 Net.
The Mayo Clinic Number of 296 pages with 163
illustrations is of great interest and value and is a
volume in itself, of twenty-two subjects by nineteen
contributors.
Dr. D. C. Balfour presents a paper on the use of
the Actual Cautery in Treating Benign Lesions of
the Stomach and Duodenum. Dr. Balfour has done
considerable original work on this subject. Dr. C.
H. Mayo gives a clinic on Gastrojejunocolic Fistulas
Following Gastroenterostomy and on the Formation
of a Cloaca in the Treatment of Extrophy of the
Bladder.
Dr. Louis B. Wilson presents a clinic on Malig-
nant Tumors of the Thyroid, illustrated by a series
of cases — microscopic sections — and expresses the
opinion that malignant tumors of the thyroid are
more frequent than supposed. Dr. W. J. Mayo gives
a paper on Splenic Syndromes, with cases relating
to Splenic Anemia, Syphilitic Anemia, Pernicious
Anemia, Hemolytic Icterus, Primary Polycythemia
and Splenonyelogenous Leukemia.
(Continued on Advertising Page xvi)
Journal of Iowa State Medical Society
XV
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XXI. Algolagnia (Sadism and Ma^chhm)
— Appendix: A Contributloiwto the
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of an Algolagnistlc Revolutionist) . 555
Xlll. Prostitution — Appendix: the Half-
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XIV Venereal Diseases — Appendix: Vene-
real Diseases in the Homo5exual.. 840
XV. Prophylaxis. Treatment, and Sup-
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XVI. States of Sexual Irritability and Sex-
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XVI
Journal of Iowa State ]\Iedical Society
BOOK REVIEWS
(Continued from Page 204)
Dr. H. H. Bowing presents a series of cases of
Hodgkins Disease treated by radium and x-ray.
Dr. Adson, the Treatment of Brain Tumors —
among the clinics on eye and ear. Dr. New presents
a number of cases of an interesting disease known as
Rhinophyma.
Dr. Ambrose L. Lockwood presents a paper on the
Development and Possibilities of Thoracic Surgery.
An important contribution is by Dr. V. C. Hunt on
Acute Conditions of the Abdomen and one by Dr.
M. S. Henderson on Incisions of the Knee Joint.
THE SURGICAL CLINICS OF NORTH
AMERICA
December Number, 1921. W. B. Saunders
Company. Price, Paper $12.00 Net. Cloth
$16.00 Net.
The New York Number contains an account of
interesting clinics, a few of which we may partic-
ularly notice.
Fibrocystic Lesions of the Upper Portion of the
Shaft of Femur, by Dr. R. W. Bolling. This con-
tribution is of much interest and entitled to careful
reading.
Dr. H. W. Meyer presents some valuable sugges-
tions on Skin Grafting. Dr. Harold Neuhof presents
a series of clinics on Surgery of the Spinal Cord, and-
Dr. A. O. Wilensky on Fracture of the Skull Es-
pecially Relating to Neurologic Manifestations. Dr.
F. W. Bancroft contributes a case of Old Posterior
Dislocation of the Shoulder by Open Operation.
This number contains the index for volume one of
the new series.
THE MEDICAL CLINICS OF NORTH
AMERICA
Mayo Clinic Number, September, 1921. W.
B. Saunders Company. Published Bi-
Monthly. Price $12.00 Per Year.
There is need of saying little more than that the
papers were prepared from the Mayo Clinic, with
the greatest care and discrimination by twenty-one
contributors.
The first paper may be particularly noted, because
of its bearing on the diagnosis of nephritis. This
contribution is by Dr. William L. Benedict; Retinitis
of Acute Nephritis. .Another is Primary Cancer of
the Lung from the Roentgenologic Viewpoint, by
Dr. Russell D. Carman. Although infrequent, it in-
volves some difficulties in diagnosis. The symptoms
are not pathognomonic and appeals to the roent-
genologist for aid. Cardiospasm is an exceedingly
interesting subject and important in diagnosis in
stomach cases; is treated by Drs. Henry Plummer
and Porter P. Vinson.
Atypical Pain, with Angina Pectoris, must appeal
to every general practitioner, is presented by Dr.
Frederick A. Willins.
In reviewing the communications in this number,
all highly important, we find difficulty in selecting
one paper more important than another, and can
only single out a few to illustrate the value and im-
portance of the Mayo Clinic Number.
THE MEDICAL CLINICS OF NORTH
AMERICA
November Number, 1921. W. B. Saunders
Company, Published Bi-Monthly. Price Per
Year $12.00.
The number before is a Philadelphia number and
contains clinics number from some of the foremost
Philadelphia teachers of medicine. Dr. James M.
-\nders presents Some Forms of Functional Cardiac
Disturbance, in which certain psychic factors are in-
volved, the therapeutics of which has been much
neglected leading to a decreasing confidence in doc-
tors of medicine.
Dr. Joseph Sailer considers Some Mistakes in Ab-
dominal Diagnosis, which should receive serious con-
sideration and which leads to much difference of
opinion among doctors, and distress to the patients,
which might be avoided by more careful investiga-
tion.
An interesting communication appears from Dr.
Joseph V. Klauder regarding the Clinical Value of
the Kolmer Modification of the Wassermann Test,
supplemented by a paper by Dr. John A. Kolmer on
the same subject. Dr. Richard A. Kern presents a
paper on Dust Sensitization in Bronchial Asthma
which will be of interest to many.
Occult Tuberculosis (Masked Tuberculation) is
the subject of a paper by Dr. H. R. M. Landis.
Another clinic we may note is by Dr. Thomas
McCrea on Diagnosis of Acute Nephritis. We are
able only to note a few of the clinics recorded iir
this number.
BULLETIN OF THE STATE UNIVERSITY OF
IOWA
New Series No. 198. Informal Account of
Hospital Service Under the Perkins and
Kaskell-Klaus Acts.
WHAT IS CHRISTIAN SCIENCE?
By M. M. Mangasarian, Chicago, Illinois.
50 Cents.
This pamphlet of si.xty-three pages is a philoso-
phical discussion of the claims of Christian Science,
not from the standpoint of a physician but from the
standpoint of a layman of broad culture. It has been
the privilege of the writer to listen to some of the
philosophical lectures of Mr. Mangasarian and read
a number of his productions with much profit.
Jfoumal of tlje
3otoa ^tate jfHebital ^ottefp
VoL. XII
Des Moines, Iowa, June 15, 1922
No. 6
MEDICAL PROBLEMS IX IOWA*
A. ]\I. Pond, M.D., F.A.C.S., Dubuque
The science of medicine has made greater ad-
vance within the past thirt)- years than in the pre-
ceding four thousand years.
It is not surprising, therefore, that there has
been developed a class of highly trained men who
are adding daily to the sum total of scientific ad-
vance. They have left the great majority of then-
associates struggling to keep in touch, within a
reasonable degree, of what constitutes modern
medicine.
The public are informed, through the daily
press, of the conquest of one after another of
unsolved problems, and their demands made of
the attending physician have increased, both in
the degree and quality of service rendered. When
this treatment does not measure up to the stand-
ard of their ideals, there is no hesitancy in dis-
missing the doctor of medicine, and taking on in
his place one of the various schools of professed
healing art, which are a direct outgrowth of the
widespread interest in the treatment of the sick.
As if these complications were not enough,
there are those in every community who are fired
with the holy zeal of organizing various societies
for the prevention of some formerly prevalent
disease; or to look after the welfare of some de-
pendent class of citizens; or for the building of
sanataria for this or that disability, until the
conspiracy of these events have been classed un-
der the head of state medicine. So many of the
ills of the medical profession are ascribed to the
coming of state medicine, that a certain number
of easily excited or emotionally inclined indi-
viduals, have raised the heads of these “bogie”
terrors among their fellows until they have suc-
ceeded in convincing some of the local leaders
of impending dangers, which range all the way
from being robbed of individual privileges, to the
compulsory submission of a state or governmental
commission.
There is no doubt whatever that there exists
some sort of a strained relation between the pub-
lic and the medical profession. It is quite becom-
ing, therefore, for us to attempt at this time some
analysis of this situation, and if possible classify
the causes and outline a remedy.
In the first place let us set aside the fear sug-
gested to us, and approach the consideration of
this problem in a calm and courageous manner,
and with an earnest attempt to weigh the subject
frankly; face and acknowledge the failures of
our profession, and also take our stand for, and
defend the advance made by our profession.
We live in an age of intensified invention and
competitive industry, but we forget so easily, or
we prefer to lull our awakened conscience by the
fact that in the past our treatment served us
well — so why bother about these new fangled no-
tions.
We forget the day when a doctor was sum-
moned to a call by messenger either on foot, or
horseback. We are only partially conscious of
the fact that by the ingenuity of man a great
force of nature has been harnessed, and the mes-
senger of old has been replaced by a centralized
organization in the local telephone office, and
that this invention has relieved many men and
horses of today of running errands. Today this
is all done in a fraction of the time, and with
greater accuracy than in former days.
The doctor of even twenty years ago responded
to these calls either on foot, if the case were in
the neighborhood, or at best after a horse or team
was made ready to convey him to the bedside.
Today a doctor would not think of walking to a
case even in a village. He drives an automobile —
another invention of ingenious mankind, and a
very large number of these medical men support
a conveyance which would eclipse in splendor the
most gorgeous equipage of former days. No
doctor would think of beginning his practice to-
day without a telephone, or without an auto-
mobile.
The future gives very splendid promise of even
more radical changes in the manner of receiving
calls and responding to them. What, with the
radio phone, and safe transportation by air, may
*President’s Address Iowa State Medical Society, May 11, 1922.
206
Journal of Iowa State Medical Society
[June, 1922
we with conservative reason look forward to?
The way of the successful doctor has materially
changed. There was a time when a country boy
who had to drive a team many times around a
field in order to plow it, dreamed of a profession
as an easy way to make a living. If those dreams
were real enough he would get a book, and after
his day’s work in the field would lie down in
front of a flickering fireplace and dig out the
rudiments of an education. Later he would deny
himself many necessities and all luxury in order
to put himself through college ; live on practically
nothing; think much, and as a reward of starva-
tion and want, finally receive his diploma. But
with that diploma also went a certain amount of
self-reliance and a degree of moral stamina,
which are not so commonly found today. Now
he may have the lights; books may be had from
the library, and a college education is given by
the state at less than its cost. The students have
fraternities ranging throughout the Greek alpha-
bet. They have recreational bureaus, and co-
education, and a student of today lists among hi«;
legitimate expense, bunches of American beauties
and boxes of chocolate fudge.
This modern graduate of medicine is, however,
a factor we must reckon with, and as a society
of the great state of Iowa we should endeavor to
create in every county the facilities that modern
medicine may require, so that these bright, highly
trained men may be attracted to the smaller com-
munities usually denied such service.
It is a common belief that the state of Iowa
has never produced a medical man whom the
world called great. Perhaps much depends upon
the attributes of the great. Perhaps the sacrifice
of one’s life for the advancement of a scientific
truth which has proved of inestimable value to
countless generations, can be considered true
greatness. If so, Iowa has been signally honored
by the services of Dr. Jesse W. Lazear, a young
man from Davenport, who died September 25,
1900, a martyr in the experimental work done in
yellow fever by the United States Army.
Within the past sixty days the writer heard a
representative of the Rockefeller Foundation say,
that in his survey of the state he found something
over 70 per cent of the Iowa doctors were gradu-
ates from Class “A” medical schools. This per-
centage is not exceeded by any states in the
Union so far as the survey has been made.
The Journal of the Iowa State Medical So-
ciety ranks among the first five in the list. Iowa
takes twelfth place in the line of accredited hos-
pitals in the American College of Surgeons, and
while we may not be able to lay claim to the fact
that the membership list of our society contains
many names of nationally or internationally
prominent men, we can and do proudly claim that
our society is made up of medical men of a higher
general aveiage than falls to the lot of most
states.
\\ e would be ashamed if our profession had
not kept pace with the advancement of other
branches of science or invention. However, we
are not quite so keen about appropriating the ad-
vances in diagnosis and treatment as we are to
obtaining the case or the patient. Willingly
would we install our telephone and build our
garages, and buy our autos, and straightway be-
come so busy that we have not the time to give
our patient the benefit of a fraction of the re-
sources modern medicine offers us in treatment
or diagnosis. We lose sight of the fact that
virtue is its own reward, and that the art of a
thorough physical examination has done more to
build the fame and reputation of successful doc-
tors, than the display of all sorts of costly equip-
ment in their office.
The x-ray is a most valuable adjunct to con-
firm a suspicion founded upon a physical exam-
ination, but it can and does lead to serious error
unless used as an adjunct. Routine AVassermann
and blood chemistry examination would clear
many a perplexing problem of case history, and
even a careful urinary examination may fre-
quently point to a diseased right kidney and thus
save the more easily accused appendix, or gall-
bladder ; or reveal to the careful examiner the
existence of diabetes, the gastric crises of which
has resisted the treatment for stomach disease in
the hands of his careless neighbor.
Thus comparisons and similes could be con-
tinued almost indefinitely, but would not serve
the purpose of emphasizing the importance, the
prime importance of a careful, painstaking, phy-
sical examination no better than has been accom-
plished.
The great clinics of America, and presumably
of other countries, flourishing at this time, may
very properly ascribe their generous patronage co
the failures of the careless, or hurried, or in-
different doctors, who at the first opportunity
failed to make a diagnosis.
Would it be interesting to note that in three
thousand cases of fractured femur occurring in
North America during the year 1920, but ninety-
four of them recovered, with the result of a dis-
ability of 10 per cent or less ? How many of us
would acknowledge that we could not treat a
fracture of the femur with a better average? In
the state of Iowa during the year 1920, more than
VoL. XII, No. 6]
Journal of Iowa State Medical Society
207
twenty-five hundred young women gave up their
lives during child birth. How many of us would
acknowledge an obstetrical ability of such an
average ?
It is logical, therefore, that there should arise
a class of healers who will make capital out of
the unfavorable results of the earnest and honest
doctor, and establish some new system or school
of healing which promises more than they could
by any reason hope to fulfill. Nevertheless, they
are received by the community as healers, and if
the medical profession seek to have laws passed
regulating the educational standards of those who
profess to care for the sick, then a cry arises from
the ranks of the new cult, of persecution, which
immediately attracts to its cause many legislators
who pride themselves upon the representations of
the great American principle of liberty.
Thus they are licensed and permitted to prac-
tice as a class, and privileged to a lower standard
of preparation than is exacted of the medical pro-
fession. We have as a result a choice variety of
“pathies,” “praetors,” “healers,” “rubbers,” etc.
The doctors of twenty years ago had these
same problems and trials from the same cause.
It is not so very long ago that the question was
asked, “Are you an ‘Allopath,’ ‘Homeopath,’ or
‘Eclectic ?’ ” Time has solved these problems and
in so doing has obliterated the dividing class
lines.
The requirements of education for all who
graduate as a doctor of medicine have become
standardized, and we have as very prominent
members of this society, many men who took
their medical course in schools other than the
regular school of medicine, and let it be said to
their credit, that they have reflected honor and
distinction, by their experience, upon the Iowa
State Medical Society.
Just why the public activities in relief of suf-
fering, or want, should be classified under the
head of state medicine, does not readily appear.
When the various organizations were being
formed in this state, some doctors were invited to
participate; for some reason they declined ser-
vice, but offered advice. The men who were
sponsors for these movements were successful
business men, and they were determined to see
these organizations completed and perfected.
They would like to have some doctors associated
with them, and be glad of their counsel, but if the
doctors shied at this movement by reason of real
or fancied ethical restriction, then, they proposed
to go on with it in any event, and the medical pro-
fession could go hang.
The Red Cross was organized in Iowa by wide-
awake, efficient business men with ideals. The
Iowa Tuberculosis Association, The Iowa Visit-
ing Nurses Association, The Iowa Council of So-
cial Welfare — all of them, if not organized by the
same group of prominent citizens, were certainly
supported by them financially and morally. All
of these activities are in response to the modem
demand of a public need.
We Live in the Twentieth Century
We are not driving a horse hitched to a gig any
more. That was yesterday. We drive a “horse-
less carriage” which became an automobile. To-
morrow we may go by aeroplane. Let’s get ready
today to fly tomorrow. No one can tell what
problems in professional affairs the future has
for us, but we can be ready for almost any ova-
tion which rings true, comes in response to a
public need and is devoid of selfishness.
Now when the subject of public health, pre-
ventive medicine, social hygiene, health insurance,
pre-natal institutes, community hospitals, baby
folds or infant welfare bureaus are mentioned,
the hue and cry goes up of state medicine. This
attitude of the medical profession lets us in for
some justifiable criticism. Just why should not
the profession of Iowa be interested in all of
these functions, and just why should not the Iowa
State Medical Society with its component countv
societies recognize these associations as expres-
sion of a public need? Just why should we not
co-operate with these organizations and if possi-
ble enlist other factors to join the movement —
The State Board of Health, The Medical School
of our University, and the Extension Division of
our State Institution? By co-ordinating all of
these allied factors might not the Iowa State
Medical Society broaden its usefulness by becom-
ing actively interested in public welfare ?
It stands to reason that the State Board of
Health could function more efficiently in every
department of its scope, if assured of the hearty,
constructive co-operation of the entire State Med-
ical Society. Public Health and Preventive Med-
icine should have an active part in the program
of our state society, and if we do not see to it that
some provision is to be made for a discussion of
these subjects, we can very surely look forward to
the time, in the near future, when there will be a
separate and distinct organization for those in-
terested.
Can we afford this continuous division of our
membership? Would it not be far better for all
concerned that we make the provision for a rep-
resentation of these various organizations of al-
lied medical and health problems, and thus give
our own members the advantage of the best
thought along these lines, than, by indifference.
208
Journal of Iowa State Medical Society
[June, 1922
or lack of interest, permit the organization of an-
other group?
Dr. Donald iMacrae in his president’s address
last year, sounded a note of distinct and real
progress for our Society. A committee was ap-
pointed in harmony with his suggestions, and this
committee is ready to report.
In closing, therefore, let us not be pessimistic.
Conditions in our state do not warrant a gloomy
attitude. However, they do require some clear
thinking, some deliberate action, and unselfish
and generous motives to bring what may appear
on the surface to be contending forces, into a
camp of united effort for the prime purpose of
the service.
When we graduated in medicine our diploma
conferred upon each of us a degree of being qual-
ified to “treat the sick.” Let us stick to that
qualification and make it our ideal in the biggest,
best and most practicable manner possible.
“Don’t blame the ivorld when things go wrong
And yon have met rebuff,
Don’t censure any of the throng
Who choose to call your bluff;
Investigate and you will find
That what I say is true.
Don’t tell me that this world’s unkind
It’s not the world, ifs you.’’
TYPES OF SEVERE AXEMIA*
With Especial Reference to Secondary
Hypoplastic Anemia
Alfred Stengel, ?iI.D., Professor of Medicine,
University of Pennsylvania, School of
Medicine, Philadelphia, Pa.*
The anemias have in recent years been gener-
ally classed under some such scheme as the fol-
lowing :
1. Post-hemorrhagic — acute and chronic.
2. Secondary or symptomatic.
3. Anemia due to disturbance of hemogenesis :
(a) Chlorosis, (b) Aplastic anemia — primary
and secondary, (c) ^Myelophthisic anemia (in-
cluding anemia associated with leukemia).
4. Anemias due to hemolysis: (a) Toxic
group. (b) Symptomatic hemolytic anemia,
"(cl Ictero-anemia. (d) Pernicious anemia.
1. Hemorrhagic anemia presents clear cut pic-
tures when it is acute in its development and also
in more chronic cases when considerable losses of
blood have occasioned rather marked anemia
•Presented at the Tri-State Medical Society of Iowa, Illinois and
Wisconsin at Milwaukee, November 15, 1921.
from the beginning. In cases in which small
losses of blood have occurred over a long period
of time there is often a picture that is not so clear
and it is probable that such cases may at no stage
present the marked features of the acute or of the
more rapidly developed chronic group. These
very slowly developed chronic hemorrhagic an-
emias from small blood losses are relatively un-
common and will not be further considered at this
point. Ordinary post-hemorrhagic anemias are
clearly indicated by the more or less pronounced
reduction in red cells and the relatively greater
reduction in hemoglobin. There is little change
except some pallor in the appearance of the red
cells, but nucleated red cells (normoblasts) are
frequently found and may be abundant. Leucocy-
tosis is usually present and the polymorphonu-
clear neutrophiles predominate. Repeated large
hemorrhages extending over a considerable pe-
riod of time occasion a form of anemia not dis-
similar from that just outlined except that there
is a greater reduction in the number of red cells
and considerable alteration in their morphology
is frequentl}' observed, ^^ariation in the size and
shape of the cells, are more striking than poly-
chromasia. Erythroblasts are less abundant than
in the acute cases and leucocytosis is less marked,
except perhaps immediately following one of the
recurring hemorrhages.
The hemotologic features of post-hemorrhagic
anemia are clearly attributable to the direct loss
of blood and the dilution of the blood mass with
tissue fluids and to the subsequent increased he-
mogenesis stimulated by the loss.
2. Secondary or Symptomatic Anemia occurs
in a great variety of diseases including infec-
tions, parasitic diseases, malignant tumors, and
intoxications. The hematologic features in the
acute and chronic cases vary somewhat as do
those in acute and chronic post-hemorrhagic an-
emias, and there are minor variations in the case
of anemias due to different infections, parasites
or intoxications. In general, however, we find
in the more acute cases a chloro-anemic picture
similar to that seen in acute anemia after hemor-
rhage, but with, as a rule, less tendency to the ap-
pearance of nucleated red cells, while leucocytosis
is often distinctly more marked. Changes in the
morpholog}- of the red cells are slight even when
the anemia is quite severe. Exceptions to these
statements occur in some cases, for example, in
the pronounced anemia of some cases of lead poi-
soning or other toxemias. In the more chronic
svmptomatic anemias greater reduction in the
number of erythrocytes and relatively less marked
reduction of hemoglobin with less leucocytosis are
VoL. XII, No. 6]
Journal of Iowa State IMedical Society
209
usual while the morphology of the red cells may
show pronounced alterations. The high grades of
anemia occasionally met with as a result of long
continued small hemorrhages closely resemble the
more chronic and severe secondary anemias.
Considerable variations in size of the red cells
and occasional or e\en abundant macrocytes,
marked poikilocytosis and decided polychromasia
are found in the severe and more prolonged cases.
Erj-throblasts are not numerous but an occasional
normablast or megaloblast may be found. The
number of leucocytes is distinctly lower than in
acute cases. With continuance and, perhaps, in-
creased se\ erity of such cases there is sometimes
a further fall in the number of red cells, occa-
sionally to below 1,000,000 while the hemoglobin
may remain nearly stationary or decrease more
slowly so that in the end a color index of 1 or 14-
instead of a lowered index is reached. The leu-
cocytes in the meantime may likewise diminish
in number to normal or below normal, the neu-
trophilic polymorphoneuclears in particular be-
coming less abundant while the lymphocytes are
in relative excess. There is a manifest and pro-
nounced difference in the blood picture of such
extreme cases as contrasted with ordinary or
even somewhat prolonged symptomatic anemias
which suggests an added pathogenetic factor.
The development of secondary or symptomatic
anemias may with probable correctness be at-
tributed in part to blood destruction and in part to
diminished hemogenesis. That there is a large
element of hemolysis in the anemia of various in-
fections especially malaria, pneumococcus and
streptococcus infection and in certain toxemias
such as lead poisoning or arsenic poisoning seems
fairly clear despite the fact that our methods of
determination do not clearly show the features
which we are accustomed to think of as evidences
of hemolytic anemia. There are, however, rea-
sons for suspecting that failure of hemogenesis is
also a factor in the development of the anemia in
these cases. So far as the latter factor may be
indicated by evidences in the blood of failure of
bone marrow activity (reduction of platelets, re-
duction of skein cells and diminution of poly-
morphonuclear neutrophiles) we have little that
is positive. On the other hand there is a marked
disproportion between the degree of anemia at-
tained in many cases and any evidence whatever
of hemolysis.
The interpretation of the cases of very severe
and it may be very prolonged secondary anemia,
in which extreme reductions in the number of
red cells, normal or high color index, normal leu-
cocyte count or actual leucopenia and more or
less morphologic variation of the erythrocytes are
the outstanding features, is uncertain, but as it 's
[larticularly this class of cases to which I desire
to direct attention, let me reserve the fuller dis-
cussion until I have completed in brief outline the
description of the other groups of anemic disease.
3. Anemias due to disturbance hemogenesis.
(a). Chlorosis, a disease which has been little
discussed in recent years, seems clearly dependent
upon some defect in blood-making. Whether
some original structural fault in the mesoblastic
(erythropoietic) tissues or an organic or func-
tional disturbance in the sex glands is the funda-
mental cause remains undetermined. In connec-
tion with the possibility of an endocrine basis,
one may recall the occasional occurrence of se-
vere anemia in cases of myxodema. One such re-
cent case in my own experience had suggestive
resemblances to pernicious anemia and terminated
in complete paraplegia due to spinal sclerosis.
The blood picture in chlorosis as originally de-
fined by Duncan consists of marked reduction m
the hemoglobin without reduction in the number
of the red cells, and later studies emphasized the
absence of morphologic changes in the red cells
or alterations in the number or kind of leucocytes.
While this is the picture of freshly develope^l
cases, considerable change takes place in un-
treated or inadequately treated cases that have
become chronic. In these one finds decided
diminution in the number of red cells and conse-
quently less pronounced disproportion in the per-
centage of hemoglobin and corpuscles. It is
clearly the inclusion of cases of this advanced
type that has somewhat changed the picture of
the disease as described by some authors of later
date than Duncan (see VonNoorden’s article
“Chlorosis” Nothnagel’s Cyclopedia, American
edition). That this change occurs in prolonged
and uncured chlorosis was noted by various ear-
lier writers and has been clearly shown in a num-
ber of my own cases where the earlier (Duncan)
picture was followed by the later features. In
this late stage the disease is hematologically indis-
tinguishable from many cases of undoubted sec-
ondary anemia. To those cases of secondary
anemia in which the poverty of hemoglobin is es-
pecially marked, it has become customary to give
the title Chloro-anemia, while in an adjective
sense the term Chloro-anemic is used for any
anemia even tending in this direction. The recog-
nition that secondary anemia may present this
type of chloro-anemia and that the underlying
cause of a symptomatic anemia may be obscure
has led most of us in recent years to classify as
secondary anemia cases which may well have
210
Journal of Iowa State Medical Society
[June, 1922
been chlorosis and it is notable that hospital sta-
tistics contain less and less reference to this dis-
ease. Chlorosis, however, is a definitely estab-
lished condition and should no doubt be more in
our thoughts than it has been of late. . That it
may grow into a form that more strongly suggests
secondary anemia than the picture which is usu-
ally described and may finally, in exceptional
cases, resemble pernicious anemia is quite cer-
tain. Some of my case reports of refractory
types followed through a series of years indicate
this very clearly.
(b) . Aplastic anemia may be a primary condi-
tion of obscure etiology or may be secondary to
definite causes. The former is a disease now
Cjuite well recognized in which rapidly increasing
anemia occurs without any clear indications of
hemolysis but with evident failure of blood mak-
ing function as is shown by the usual absence of
nucleated red cells, and the great reduction in the
number of skein cells and platelets, of the total
number of leucocytes and of the polymorphonu-
clear elements in particular. A marked hemor-
rhagic tendency is found to correspond with the
diminished number of platelets.
A secondary form of asplastic anemia results
from certain forms of intoxication, very strik-
ingly from benzol poisoning as was shown in the
report of one of my cases in a workman exposed
to a “spill” in an aniline dye works. Less con-
spicuous cases are no doubt fairly common and
are likely to increase in frequency with the more
extended use of benzol and its derivatives or re-
lated poisons in various industries. In this con-
nection I wish to state that a somewhat striking
occurrence of cases of severe anemia among
chauffeurs and men working about garages has
impressed me of late.
The hematological features of these toxic cases
may closely resemble those of primary aplastic
anemia though there are, as a rule, greater alter-
ations in the morphology of the red cells, and
other features including jaundice, suggesting
some associated hemolysis.
(c) . Myelopthisic and post-leukemic anemia
and that following exposure to radiation. The
destruction of the marrow by metastastic tumors
or leukemic infiltration is known to produce a
type of anemia, sometimes intense and with evi-
dences in the earlier stages of marrow excitation
and later of hypoplasia or aplasia of the marrow.
Similar results (without the earlier excitation)
occur in cases of prolonged radiation, particu-
larly, I believe, where the treatments have been
directed over the marrow.
In all of these conditions there is essentially a
direct destruction of marrow with resulting loss
of hemopoietic function. The anemia that re-
sults may be extreme but does not present fea-
tures suggestive of a hemolytic factor in the
etiology.
4. Anemia due to hemolysis, (a). Toxic
group. Marked hemolytic anemia may be caused
by various forms of poisoning such as T. X. T.,
Di-nitro benzol, chlorate of potash, acetanilid or
the venoms of certain animals. Certain infectious
anemias occasionally fall in this group. Such
cases are distinguished from ordinarj' secondary
infectious anemias, in which the probability of a
hemolytic factor, is admitted though not evident,
by the excessive degree of hemolysis and its con-
siiicuousness in the clinical picture.
Rapidly increasing destruction of red cells with
pronounced morphologic changes in the circulat-
ing erythrocytes and the development of jaundice,
enlargement of the spleen and increased output
of urobilin or other blood pigments are con-
spicuous in this group. It is unnecessary to dis-
cuss more fully the features observed.
(b) . Symptomatic hemolytic anemia may oc-
cur in occasional cases of pregnancy, lues, or car-
cinoma but are too unusual to warrant further
discussion.
(c) Hemolytic Ictero-Anemia — congenital, or
acquired and of varying grades of severity,
constitutes a group in which the associated
splenic enlargement and jaundice with the in-
creasing anemia and, as a rule, increased fragility
of the red cells are conspicuous features. In the
earlier stages and especially in the congenital
form comparatively moderate changes in the
erythrocytes may contrast with the other clinical
features. The red cell count may' also be little
altered from the normal or, at least, may not be
reduced below that of moderate anemia ; but as the
disease advances, marked changes in the mor-
phology of the erythrocytes and profound anemia
may' develop and at times hemorrhagic phe-
nonema complicate the picture and increase the
impoverishment of the blood. In several cases in
our series the disease terminated as a grave pur-
puric condition. The blood picture in advanced
stages gives evidence of the hemolytic' nature of
the disease — marked changes in the red cells,
fragmented cells, polychromasia and pigmented
cells — while throughout the disease and before
any' changes in morphology are discovered exces-
sive urobilin excretion signifies the augmented
blood destruction.
(d) . Pernicious Anemia. All modern writ-
ers regard this severe and eventually fatal dis-
ease as es.sentially a hemolytic anemia and give
VoL. XII, Xo. 6]
Journal of Iowa State Medical Society
211
little or no consideration to the older view that
faulty hemopoiesis may be a contributing factor.
Some designate the disease simply as cryptogenic
hemolytic anemia and nearly all agree that the
blood destroying agent whether infectious or
toxic is of unknown source. I shall not delay
even to mention the various views held regarding
possible origins. The recognition of the disease
when pronounced and typical offers no serious
difficulties. The extreme reduction in the num-
ber of the erythrocytes, their marked alteration in
size and shape, the presence of more or less
abundant bizzarre forms, the occurrence of de-
cided polychromasia, of pigmented (granular)
red cells and of erythroblasts, especially megalo-
blasts, and the presence of a large number of
erythrocytes of excessive size (magalocytes)
gives the blood picture of typical cases a path-
ognomonic character. Furthermore, the appear-
ance of the patient (yellow or icteric color), the
increased excretion of urobilin in the urine and
the excess of total urobilin in the feces and urine
are significant features. Unfortunately, there
are cases of quite advanced stage in which the
character of the blood and the clinical conditions
are atypical and on the other hand, pronounced
hemolytic anemias of other kinds and sometimes
secondary anemias may closely resemble perni-
cious anemia in their hematologic manifestations.
Additional confusion is caused by the fact that
in its earlier stages and during remissions, the
blood picture may be verj' slightly suggestive of
the disease. The recognition of the disease is.
therefore, far less simple than is sometimes be-
lieved and errors of omission as well as of com-
mission are not infrequent. That we may make
as few as possible of the former type of errors it
is necessary to review the data already mentioned
as well as some additional clinical features to
determine, if possible, the limitations of the term
pernicious anemia.
1. Fatal Termination not Diagnostic. In
early descriptions of the disease emphasis was
placed upon its fatal termination and it is clearly
evident in the literature that the tendency to a
fatal termination is one of the factors in diagno-
sis that has been given great weight. In practical
clinical experience, I believe few of us have failed
seeing cases which have been regarded as perni-
cious anemia because they were instances of se-
vere anemia without any discovered cause and
unrelieved by treatment and despite the fact that
the clinical and hematologic features as a whole
did not warrant such a diagnosis. That this is a
common error of those not especially familiar
with blood diseases, my experience compels me to
believe. Though we may find ourselves unable to
differentiate the type of profound anemia, we
should recognize that the evident lethal tendency
of the case does not justify the diagnosis of per-
nicious anemia. It must, of course, be conceded
that when the hematologic features suggest the
diagnosis inefficacy of all forms of treatment and
a fatal ending warrant a positive decision.
2. Morphologic Changes in the Red Cells.
The combination of all of the recognized abnor-
malities in the blood picture undoubtedly estab-
lishes the diagnosis almost positively, but cases
otherwise typical may be wanting in one or more
features.
Marked alteration in the character of the red
cells may be absent in early stages and may dis-
appear during remissions, and exceptionally may-
be long delayed in their appearance in cases other-
wise quite definite. I recall one in which during
a year of increasing anemia never typical in the
count and color index, there was a complete ab-
sence of morphologic change in the red cells and
no erythroblasts were found, yet spinal degenera-
tion occurred and finally caused complete para-
plegia, the tongue was characteristic and before
death the blood picture was nearly' typical. Ex-
cept in early stages and in remissions such ab-
sence of morphologic changes is rare and a diag-
nosis in their absence is difficult, indeed.
Erythroblasts. Great weight is given to the
significance of nucleated cells and it has some-
times been suggested that the absence of such
cells or even of the form termed megaloblasts
should exclude the diagnosis. A number of
years ago a hematologist took me to task for ven-
turing a diagnosis of pernicious anemia in a case
in which there were only normablasts. Such a
criticism would hardly be made today and it is
generally admitted that blasts of all sorts may be
wanting, though usually in these cases repeated
examinations will sooner or later reveal their oc-
casional presence. Megaloblasts when present,
and this is doubtless the case in the majority of
instances, are especially- significant, but they' are
not diagnostic as we well know they may occur in
occasional severe anemias of other sorts.
Megalocytosis — not the presence of an occa-
sional large form but a definite increase in many — ■
perhaps an average increase in size — is highly
significant and rarely met with except in this
disease. Its absence does not exclude the diag-
nosis when other conditions strongly- indicate it.
The other morphologic conditions taken sep-
arately— anisocytosis, poikilocy-tosis, polychroma-
sia and granular pigmentation — must not be
given undue weight but are features that are usual
212
Journal of Iowa State ^Medical Society
[June, 1922
and important in the whole picture and taken to-
gether are significant though not diagnostic.
3. Evidence of Hemolysis. e rely upon the
yellowish color of the patient or the blood plasma,
fragmentation and other marked changes in the
red cells, urobilinuria and increase of total uro-
bilin in feces and urine, and enlargement of the
spleen (which is somewhat proportional to the de-
gree of hemolysis) as the best evidences of blood
destruction. Estimations of the urobilin in the
feces and urine or in the duodenal fluid would
appear to be the most exact method and are un-
doubtedly in quantitative determinations the most
useful ; but we meet with occasionally cases of
undoubted pernicious anemia in which these
methods fail. Several have occurred in my own
recent experience. It may not be assumed from
this that pernicious anemia is not necessarily a
hemolvtic anemia, nor even that hemolysis was
temporarily absent in these cases. In each of the
instances referred to other features left little
doubt of the presence of a hemolytic process.
Similarly there are cases showing none of the
usual yellow discoloration while urobilin tests are
positive. The evidence, as a whole, rather than a
single criterion must be relied on, and it must
also be remembered that a certain yellowness of
the skin may be found in non-hemolytic second-
ary anemias just as it occurs in certain individuals
who have suddenly grown faint or in a person
suffering from acute nausea.
A diminution of platelets, less marked than in-
aplastic anemia, a leucocyte count nearly normal
or below normal but less decided leukopenia and
relative lymphocytosis than are found in aplastic
anemia are other factors in diagnosis.
Diminished fragility of the red corpuscles is
commonly present in pernicious anemia and has
a certain slight value in distinguishing this condi-
tion from severe secondary anemias. It is, of
course, in sharp contrast with the increased frag-
ility of ictero-anemia.
Some increase in the percentage of skein cells is
usual in the earlier stages and generally through-
out the whole disease. In late stages a flagging
of hemogenesis may be accompanied by a diminu-
tion of these cells.
Among the clinical symptoms that deserve some
special consideration are the condition of the
tongue, the analysis of the gastric contents and
nervous manifestations.
A peculiar redness of the tongue, sometimes of
a raw, at other times of a shining character, with
or without thickening (glossitis) and painful sen-
sations in the mouth and especially in the tongue
are frequent early manifestations of pernicious
anemia. \\'hen combined with an evident, in-
creasing impoverishment of the blood, these
symptoms are highly suggestive, especially in pa-
tients past middle life, but they are by no means
necessarily forerunners of pernicious anemia nor
are they adequate to determine that a given
anemia, not otherwise suspicious is pernicious
anemia.
In cases of oral sepsis with severe secondary
anemia one sometimes sees precisely the same
conditions of the tongue as in pernicious anemia.
Absence of free hydrochloric acid with or with-
out the absence of ferments occurs so frequently
that it has a considerable value in diagnosis, par-
ticularly as there is far less commonly such
anacidity in cases of even the most profound sec-
ondary anemias when these are independent of
gastric disease.
jNIuch has been said in recent years of the diag-
nostic significance of nervous symptoms and in
particular of spinal cord disease (postero-lateral
column disease). While it is quite true that an
early development of numbness and tingling or
pains in the extremities, particularly in the feet, is
highly suggestive, and that in the more developed
stages of the anemia loss of the sense of position
of the toes or foot (acroataxia) and of vibratory
sensation (bone sensation) with changes in the
reflexes (knee and ankle) are significant of cord
degeneration, it must be remembered that similar
cord disease has been repeatedly described in
cases of leukemia, has been produced experi-
mentally by interference with circulation and I
may add from my own experience that it occurs
now and then in profound secondary anemia.
Nevertheless, the far greater frequency of occur-
rence of these symptoms in pernicious anemia
gives them a suggestive value in diagnosis that
cannot be ignored. In passing, I wish to state
that in a few instances I have seen the nertmus
symptoms pronounced before there was notable
anemia and this of uncertain type.
I have thus, perhaps, at somewhat wearisome
length, but without great detail reviewed the out-
standing hematologic and symptomatic features
of pernicious anemia that we may have it before
us for contrast with the conditions found in cer-
tain severe and prolonged secondary anemias (in-
fectious, post-hemorrhagic or toxic) to which I
referred in an early part of my discussion. I al-
lude to those cases in which with long continu-
ance of the cause of secondarj^ anemia and after
what appears as an exhaustion of the reparative
hematopoietic function the character of the
anemia changes, losing most of the features that
ordinarily suggest secondary anemia. These
VoL. XII, X^o. 61
Journal of Iowa State Medical Society
213
cases may reach extreme grades of severity and
they may terminate fatally, apparently without
any added cause other than the exhaustion of se-
vere anemia, and for these reasons are likely to
be regarded as pernicious anemias. Even before
the fatal issue seems immanent, failure of all
forms of treatment to improve the blood picture
suggests a diagnosis of pernicious anemia. That
there is a condition of exhaustion of the blood
making powers in cases of continued anemia
seems natural enough and was long ago men-
tioned by Laache and Ehrlich. The former found
that the I'ed cells increased from 1,600,000 to
normal in two months in a case of acute post-
hemorrhagic anemia while in a case of anemia
from repeated rectal hemorrhages (hemor-
rhoids), the return to normal from 2,500,000
erythrocytes required eight months after all hem-
orrhages had ceased. Ehrlich showed exjieri-
mentally that after repeated bleedings the re-
generation was much slower than in cases of
equally severe anemia due to a single loss ot
blood. In confirmation of Laache’s observation,
I may refer to two cases of my own in which
attempts to relieve post-hemorrhagic anemias,
after removal of hemorrhoids and cessation of ail
hemorrhage, failed completely till the anemia was
partially corrected by transfusions, after which
further improvement went on progressively un-
der medical and dietetic treatment.
Profound anemia with red cell counts below
1,003,000 and with a color index of one and one
plus may be found in the group of cases under
discussion and by reason of its severity naturally
suggests pernicious anemia. The differential
diagnosis is by no means easy and in some cases,
perhaps, impossible. A careful consideration of
all of the data obtained by clinical and hemat-
ologic study must preceded any decision. Off-
hand diagnoses are the cause of most mistakes
and it is important to remember that the possible
discovery of a cause for a severe anemia may
lead to successful treatment, whereas, a decision
in favor of i)ernicious anemia will usually be fol-
lowed by abandonment of any serious efforts.
A study of these cases of profound secondary
anemias shows an absence of evidences of hem-
olysis, excepting that some fragmentation and
other morphologic changes in the red cells may be
suggestive. The urobilin excretion is subnormal,
the color of the skin and plasma of the blood are
not suggestive of hemoloysis (though a certain
yellowness of skin without change in the sclera
may be seen in advanced and somewhat rapidly
developed cases). On the other hand pernicious
anemia may be suggested by the fact that the
number of leucocytes falls with prolongation of
the anemia until a normal figure or possibly even
a moderate leukopenia is reached, while the neu-
trophile polymorphonuclears diminish progres-
sively and relative lymphocytosis (not as a rule
as great as in pernicious anemia and much less
than in primary aplastic anemia) follows. Nu-
cleated red cells of all kinds are usually wanting;
exceptionally a normablast or even megaloblast
may be found. In most cases the red cells show
much less morphologic alteration than that which
is common in pernicious anemia, and polychro-
masia and granular pigmentation are far less con-
spicuous. True megalocytosis is decidedly ex-
ceptional though here and there a large giant red
cell may be found. The blood platelets are often
definitely reduced though less decidedly than in
pernicious anemia. Skein cells are commonly in-
creased in number in pernicious anemia and are
usually reduced in number in this group. Inter-
current infections provoke a reactive neutrophile
polymorphonuclear leucocytosis much more fre-
quently than is the case in pernicious anemia ; but
in the latter disease, I have sometimes seen this
quite marked though it is more often wanting or
very slightly evident.
Enlargement of the spleen is distinctly more
common in pernicious anemia than in the type of
se\ere secondary anemias under consideration,
but there are, of course, instances of the latter
group (infectious, toxic) in which splenic en-
largement may be a striking feature.
A consideration of these facts has led me to
classify these cases as secondary hypoplastic
anemia and I wish to emphasize the imjiortance
of recognizing the type because it evidences one
of the tendencies of unrelieved chronic anemia
and because of its suggestive resemblance to per-
nicious anemia.
I would not wish to give the impression th.at
.such a hypoplastic or asthenic condition of the
hematopoietic system ami especially the marrow
is peculiar to any special form of anemia. I be-
lieve that it underlies the development of the con-
dition, much discussed in former years, known as
late chlorosis ; and it may be the end stage of
anemias due to continued slight losses of blood
and various toxic anemias, whether hemolytic or
otherwise, as well as the prolonged anemias of
mild sepsis — focal infections, chronic infective
endocarditis, etc. There are also similar changes
in the blood picture in chronic leukemia, after
x-ray treatments and in cases of continued ictero-
anemia. But in all of these, except the hypo-
plastic anemia following obscure secondarv
anemia some features of the earlier conditions re-
214
Journal of Iowa State Medical Society
[June, 1922
main and the diagnosis is, therefore, less obscure.
When it has developed gradually from a second-
ai'v anemia of obscure etiology the end picture
may superficially resemble that of pernicious
anemia so closely that careful blood studies and
searching clinical investigations alone will enable
the clinician to exclude the diagnosis of perni-
cious anemia. Less frequently primary aplastic
anemia is suggested and is to be excluded by a
full review of the clinical course of the case and
by the absence of the pronounced evidence of
failure of bone-marrow function characteristic
of this disease.
THE PRESENT STATICS OF THE TREAT-
MENT OF PERNICIOUS ANEMIA*
Philip B. McLaughlin, IM.D., F.A.C.S.,
Sioux City
A general summing up of the treatment of per-
nicious anemia for the past years, leads a person
over a varied course, but after reading the re-
sults, all have terminated practically the same
way, namely in failure, and no treatment of per-
nicious anemia directed against its cause has yet
been found successful, except for the forms pro-
ducted by intestinal parasites, especially the
Bothriocephalus latus, and as a matter of fact
the removal of the worm in these cases first
demonstrated that the parasite was responsible
for the disease.
Acting upon Hunter’s hypothesis that the dis-
ease is a streptococcus infection several investi-
gators namely, IMcPhedran, \\ alsh and others
have tried the effects of an anti strepticoccus
serum, but the results were uniformly disappoint-
ing. X’arious forms of mouth washes, and in-
testinal anti-septics have been tried on the same
hypothesis.
Hunter’s suggestions for treatment were, anti-
sepsis of mouth, gastrointestinal antisepsis, ad-
ministration of arsenic and anti-streptococcus
serum. Some investigators guided by the results
of organotherapy, in other diseases, have tried it
in pernicious anemia, proceeding on the assump-
tion that the disease takes its origin in the bone
marrow. In administering marrow, they have
sought a casual therapy, also drug houses have
supplied an elix of red bone marrow. The liter-
ature contains reports of such treatment from
Frazer, Barrs, Drummond, Pepper and Stengel
Grawirtz and others, the last named authority ob-
served absolutely no results from its administra-
*Read before the Seventieth .Annual Session, Iowa State Medical
Society, Des Moines, Iowa. May 11, 12. 13, 1921.
tion, while others attribute to it the recoveries in
several of their cases. The most authentic re-
ports see in the administration of bone marrow
only a treatment, and not a very energetic one.
In 1877, Byrom Bramwell recommended the use
of arsenic in pernicious anemia, this remedy has
been employed more than any other, and has at
times even acquired the reputation of a specific.
Padley was first to show a series of comparative
statistics in regard to the results of treatment
with iron and other remedies on the one hand and
with arsenic on the other. Among forty-eight
cases in the first group, forty-two died, two were
still under treatment, in three the results were
not given, one was cured. Among twenty-two
treated with arsenic, Padley observed sixteen re-
coveries, two improvements, four deaths. Among
fifty-seven treated with arsenic, Furbringer re-
ported four relatively cured, si.xteen improved,
ten unimproved and twenty-seven deaths.
You will notice no relative time is given as to
the length of time occupied by the treatment, or
as to the length of time the patients reported
cured remained so. The administration of phos-
phorus, quinine and the inhalation of oxygen,
have been tried in seieral cases, and are men-
tioned only for the sake of historic interest.
In the general management and diet of a case
of pernicious anemia, we have two very import-
ant adjuncts and I must say in a number of cases
are veiw often neglected entirely. I do not care
what your treatment of the case may be, if you
neglect the nutrition of your patients and do not
see to his comforts of living, symptoms will soon
set in, that will take your j)atient off. To keep
up the nutrition of the patient is sometimes ex-
ceedinglv difficult. In severe cases the vomiting
and absolute distaste for every kind of food may
render it impossible to gi\ e any nourishment in
quantities worthy of consideration. For a time
after vomiting ceases, we must be extremely cau-
tious and limit ourselves to the frequent adminis-
tration of small amounts of liquid nourishment.
As a rule, milk or mixtures of milk with coffee,
tea or cocoa, and grits, rice, vegetable soups are
borne be.st, strong irritants like alcohol, strong in-
fusions of tea, coffee, or even concentrated bouil-
lon are not borne at all. Solid food is to be in-
troduced into the menu, very gradually, just as
in other severe gastrointestinal infections. A
very frequent symptom even during advancea
convalescence is a marked di.staste for meat. We
can and must reckon on this, and limit the patient
to a vegetable diet, as a matter of fact, this has
recently been strongly recommended in anemtc
conditions. According to Musser this vegetable
You XII, No. 6]
Journal of Iowa State Medical Society
215
diet is the best means of combating the increased
intestinal decomposition so that in some cases, we
are perhaps actually administering a casual ther-
a[)y. The most important prescription regarding
the general management of living, is complete
rest. In severe stages of the disease the patient^
is constrained to avoid every effort, on account
of his intense muscular weakness, but with im-
provement, like convalescents generally, he read-
ily overestimates his strength, even during remis-
sions he should confine his exertions within the
limit of fatigue.
The same advise of rest is applicable to intel-
lectual work, moreover, every mental excitement
must as far as possible be eschewed. These pa-
tients possess very slight power of resistance to
extremes of temperature and must be protected
by special room temperatures, or corresponding
clothing. A climatic treatment may be consid-
ered in the case of more resistant patients.
The present day active treatment of pernicious
anemia seems to be gradually falling under the
domain of surgery, how long it will remain so 1
am not able to say. But beyond a question of a
doubt, the be,st tonic that can be administered to
these patients in almost any stage, is blood trans-
fusion, preferably whole blood. I have seen a
patient in complete collapse, vomiting incessantly,
delirious, and when brought to the o^^erating
room for transfusion looked as though he might
die any minute, and after receiving 800 cc. of
whole blood, rapidly recover from all extreme
symptoms, have a remission established and live
for eight months in comparative comfort, of
course such results do not happen in all cases, I
simply mention this one to illustrate what may be
accomplished by blood transfusion. Dr. N. 1\1.
Percy, of Chicago, whose work on this disease
covers a wider field than any other man has car-
ried out his treatments along the lines of Hunter’s
views, namely the infective origin of pernicious
anemia, has found evidence of infective foci in
95 per cent of cases examined. In a series of
nine operations for pernicious anemia specimens
removed, spleen, gall-bladder, appendix, were
sent at once for pathological examinations. Bac-
teria were grown from three of the nine spleens,
from four of the seven gall-bladders, and from
six of the seven appendices. The only case not
giving a bacterial growth was one in which pyor-
rhea had long been present. The chief organism
found was the haemolytic streptococcus, and this
organism was present in seven cases, in five the
baccillus coli was found in four, streptococcus
viridens.
In another series of twenty-four cases pre-
ceding the nine just mentioned, Percy records the
following gross lesions.
In twenty there was chronic cholecystitis with
or without gall-stones, in seventeen of these,
there was evidence of old disease of the appendix,
in six there were infected foci in connection with
the teeth, and one in connection with the tonsils.
Sir Berkely IMoynihan, British Aledical Jour-
nal of January, 1921, in his paper on the Surgery
of the Spleen states, if the disease, pernicious
anemia, is primarily a hemolytic process, a pro-
cess in which red cells destruction is the outstand-
ing feature, what is the nature of destruction and
whence does it come ?
Hemolvsis of definite origin are known, in the
hemolytic anemia of pregnancy a definite hemoly-
sin has been found in the placenta. In the anemia
due to bothriocephalus, cholesterase is set free by
the decomposing segments of the worm, afford.s
the poison for the red cells, though every har-
borer of this parasite, is not equally susceptible
to the action of this substance. In some forms of
cancer, especially of the stomach and ascending
colon, poison appears to be liberated which causes
a blood picture hardly distinguishable from that
of pernicious anemia.
Chronic carbon monoxide iwisoning among
charcoal workers, industrial lead, and perhaps
arsenic poisoning appears to oj)erate ill the same
manner. It is suggested that hemolytic sub-
stance fonned by pathological bacteria in the
intestines may gain egress by this route, as fir-^t
suggested by Hunter. J. H. King, after careful
studv of three cases of pernicious anemia treated
by splenectomy, and after conducting a series of
experiments upon dogs, concludes that in perni-
cious anemia, hemolytic jaundice, and cirrhosis
of the liver, the hyperactive spleen unfavorabh
influences anemia through its regulation of the
highly hemolytic unsaturated fatty acid of the
blood. The removal of the spleen therefore ap-
pears to be indicated. Splenectomy itself, besides
influencing the production of hemolytic unsat-
urated fatty acids, raises the percentage of anti-
hemolytic substance in the blood, that is, the total
fats and cholesterines. Dr. X. M. Percy of
Chicago outlines his method of treating perni-
cious anemia as follows :
1. An attempt to stimulate the process of new
blood, by massive step ladder transfusion ot
whole blood.
2. An attempt to overcome the absorption of
hemolytic bacteria or their toxins, by radical re-
moval of local foci of infection.
3. An attempt to protect the newly formed
older red cells by removing the spleen. By the
216
Journal of Iowa State Medical Society
step ladder transfusion the red blood count is in-
creased, often doubling the former count, the
hemoglobin rises, the platelets and blast cells be-
come more numerous, and Howell’s particles will
sometimes appear in the blood, indicating a stim-
ulation of the bone marrow.
The general condition of the patient improves,
the appetite is restored at once, the sore mouth
disappears and sleep returns. So I will ask un-
der what other palliative treatment could this
condition be brought about.
Xext, the matter of clearing up the different
foci of infection; the teeth, the accessor}' sinuses
or any other foci that may be present, after these
have been eradicated to the satisfaction of the
different specialists and the benefit of the pa-
tient, the spleen is removed and with it the gall-
bladder and appendix if these are thought to con-
tain pathology. In Dr. Percy’s report, based on
seventy-seven laparotomies performed by him,
the spleen, gall-bladder, and appendix were re-
moved in fifty-four cases. The spleen and gall-
bladder in eleven, the gall-bladder and appendix
in four. The spleen alone in four, there were
eight deaths. In seventy-four of these patients
one or more transfusions had been performed be-
fore operation. In four, transfusion was under-
taken immediately after operation. In ten cases
a later transfusion was performed. Of the
sixty-nine cases that left the hospital five had
recurrence of symptoms at the end of four
months, and died at intervals of eight to twelve
months. Ten had recurrence at the end of six to
eight months and followed about the same course.
Forty-eight were in good condition at the end of
twelve months, of these twelve are alive at the
end of two years, nine at the end of three years,
four at the end of four years, five living nearlv
five years after operation, and one a little over
six years, the one living six years has had no
transfusion since operation. Two of the four
year year cases have been back for transfusion as
have also four of the three year cases, five of the
two year cases and eight of the one year cases.
The progress of the four cases in which gall-
bladder and appendi.x were removed without the
spleen was not so good in any instance, as was the
average of the other cases. The spleen was not
removed in these patients because it was not en-
larged, and there were no adhesions to indicate
that there had been a splenitis or perisplenitis.
Percy goes on to state that evidently some of
his patients should not have been operated upon,
as undoubtedly just as good or better results
would have followed transfusion alone, meaning
of course patients who had advanced so far that
[June, 1922
secondary changes had already taken place in the
cord and bone marrow.
The ]^Iayo Clinic reports on pernicious anemia
cases in which splenectomy was perfonned up to
.September 20, 1920, the following results. There
were fifty-three cases with three deaths, a mor-
tality of 5.6 per cent, five patients were living
between four and five years after operation,
eleven patients were living between three and
four years after operation, 22 per cent of the pa-
tients lived two and one-half times longer than
the average pernicious anemia patient lives.
To sum up. It is not claimed that splenectomy
has cured any patient of pernicious anemia. The
oi>eration is done with a low mortality. A ma-
jority of the patients show improvement and a
prolongation of life in greater comfort. One
quarter of the patients are greatly improved, liv-
ing happier and more useful lives, prolonged
from two to three years. One-half of the pa-
tients are improved in some degree, they feel bet-
ter, sleep better, and live perhaps a few months
or a couple of years longer than the average, the
remaining one-fourth of cases do not receive any
greater help than that which could be derived
from careful medical treatment, which may in-
clude blood transfusion, and the treatment of
such foci of infection, as can be found in the
mouth, nose and accessory sinuses.
PERNICIOUS ANEMIA: A STUDY OF
ONE HUNDRED AND TWENTY-
SEVEN CASES*
E. J. Rohner, AI.D., Iowa City
This pa[>er is a study of one hundred and sixty-
nine admissions, representing one hundred and
twenty-seven separate cases diagnosed as perni-
cious anemia, admitted to the State University
Hospital, from July 1, 1910 to July 1, 1920. This
group comprises eleven hundredths per cent of
the total number of admissions to the medical ser-
vice during that period. It has been the aim in
this study, first to devise some definite method
of grouping our cases, and secondly, to try and
determine the relative value of the various fac-
tors, that enter into the diagnosis of pernicious
anemia.
Sex — There were seventy-seven males, and
fifty females.
Age — There was one case in the first decade,
four in the third, eighteen in the fourth, twenty-
three in the fifth, fifty-four in the sixth, twenty-
*Read before the Seventieth Annual Session, Iowa State Medical
Society, Ues Moines, Iowa, May 11, 12, 13, 1921.
VoL. XII, No. 6]
Journal of Iowa State Medical Society
217
seven in the seventh, and one in the eighth.
Ninety-eight per cent were between the ages of
thirty and se\enty, forty-two and five-tenths per
cent were in the sixth decade. The case in the
first decade was undoubtedly one of aplastic
anemia. Of the four cases in the third decade,
two were in males, and two, in females; autopsy
proved the correctness of the diagnosis in one,
one has not been heard from. Of the two fe-
males, in each the anemia developed during preg-
nancy; each had a relapse in a subsequent preg-
nancy. Both are alive, four and five years re-
spectively, after leaving the hospital.
Family History — Nine cases gave a positive
family historv'. Six of the cases were definite
cases themselves, three were doubtful cases. W'e
had in the hospital, at the same time, a brother
and sister with pernicious anemia (both now
dead) ; another sister had died of the same disease,
and the mother was supposed to have died of lo-
comotor ataxia, more likely, subacute combined
sclerosis; a possibility of four cases in one family.
Autopsies — Sixteen cases died while in the
hospital, and eleven come to autopsy. The diag-
nosis was confirmed in ten. One case proved to
be a carcinoma of the stomach.
Classification of Cases — For the purpose of
classification, our cases were divided on a per-
centage basis ; into three groups, depending upon
the presence or absence of what might be con-
sidered ten cardinal points. These points were
selected after a review of Cabot’s article in Os-
ier’s System, iMinot’s in the Oxford Medical
Series, and Woltman’s article in the collected pa-
pers of the Mayo Clinic, 1918. The following
points were chosen :
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
CHART I
Remissions
Paraesthesiae
Glossitis
Cord signs
Color index 1 +
R. B. C. 2.5 mil. or less
Leucopenia
Abnormal R. B. C
Achlorhydria
Urobilin and Urobilinogen in xs
Per cent
10
10
10
10
10
10
10
10
10
10
Total.
100
CHART II
Group I. 70 to 100% — 85 Cases
1 yr. 2 yr. 3 yr. 4 yr. 5 yr. Tl.
Dead 37 10 7 1 1 56
Alive 6 8 4 2 0 20
Not heard from y
Group II. 40 to 70% — 32 Cases
1 yr. 2 yr. 3 yr. 4 yr. 5 yr. Tl
Dead 5 0 1 0 0 6
Alive 8 5 3 2 4 22
Not heard from 4
Group III. 20 to 40% — 10 Cases
1 yr. 2 yr. 3 yr. 4 yr. 5 yr. Tl.
Dead 0 0 0 0 0 0
Alive 4 0 2 0 0 6
Not heard from 4
CHART HI
P. A. & S. A. C.— 34 Cases
1 yr. 2 yr. 3 yr. 4 yr. 5 yr. Tl
Dead 14 4 0 3 1 2?
Alive 6 0 1 0 0 7
Not heard from 5 5
The first two points were selected from the
history; points three and four from the physical
examination ; points five, six, seven and eight,
from the blood findings; point nine, from exam-
ination of the gastric contents, and point ten,
from the examination of the urine and stools, for
evidence of increased excretion of urobilin, and
urobilinogen. The ten points were arbitrarily al-
lowed a value of 10 per cent each. In cases where
all ten points were not recorded, those which were
recorded were given a relatively higher percent-
age.
Cases ranging between 70 and 100 per ceid
were considered definite cases ; cases between 40
and 70 per cent as doubtful, and cases below 40
per cent as very doubtful cases. There were
eighty-five cases in the first group; thirty-two
cases in the second group; and ten cases in the
third group. Through correspondence, or other-
wise, all but seventeen cases were heard from
within the past month. Chart No. II records for
each group; the number dead, the number alive,
and the duration of the disease, after the cases
were first seen.
Group I. Of the fifty-six dead, ten came to
autopsy, and the correctness of the diagnosis veri-
fied in each. Of the others that are dead, in at
least one, the diagnosis may have been wrong.
The family physician writes that the patient died
with all the symptoms of carcinoma of the liver.
No autopsy was obtained. It might be well to
mention here, that in our series, twenty cases had
palpable spleens. All belonged to this group.
Group II. Of the six dead, mention should be
made of three. One died with a post-operative
pneumonia, one died of carcinoma of the stom-
ach, and one died following an exploratory oper-
ation, in which a tumor of the bowel (possibly
malignant) was discovered. Among those still
218
Journal of Iowa State ^Medical Society
[June, 1922
alive, two were anemias of pregnancy — pre-
viously referred to ; one case was subsequently
proven to be a carcinoma of the sigmoid, one
case proved to be a case of syphilis, (now well
five years later without a relapse), one case con-
siders herself well, five years after leaving the
hospital, and three years after a hysterectomy.
Of the other cases, possibly time will reveal the
correctness or incorrectness of the diagnosis ; al-
though to date, none give definite histories of
relapses or remissions.
Group III. The replies to inquiries received
from six, leads one to suspect the diagnoses were
incorrect. One case now alive, four years since
his first admission, was again studied within the
past three weeks and he again falls in this group.
Chart III tabulates our cases that were given
the double diagnosis of pernicious anemia and
subacute combined sclerosis of the spinal cord.
In this series, were included those cases in which
the symptomatolog}-, and physical findings were
referable chiefy to the nervous system. Of these
cases twenty- five belonged to Group I and six
to Group II.
CHART IV
J y j- i > ■ T /
Relative \'alue of the \"arious Diagnostic Fac-
tors— -V study of Chart Xo. IV shows that points
one, four, six, seven and eight are of more posi-
tive value than are points two, three, five, nine
and ten. In other words, the historv- of remis-
sions, the evidence of postero-lateral cord in-
volvement, an anemia of two and five-tenths mil-
lion or less, a leucopenia and abnormalities in the
size, shape and staining reaction of the red blood
cells, are of decidedly more importance than are
the history of parasthesije, the suggestive tongue,
the plus color index, the absence of free hydro-
chloric acid in the gastric contents, and the pres-
ence of an excessive excretion of urobilin and
urobilinogen. Column A indicates Group I, Coi-
umn R, Group II, and Column C, Group III.
It might be well to consider each point indi-
vidually.
1. Remission.s — In Group I, there were but
nine cases that lacked this point, eight of these
were cases with marked postero-lateral cord in-
volvement. These patients do not recognize read-
ily their blood remissions. The ninth case, ac-
cording to the report of the family physician,
died with all the symptoms of carcinoma of the
liver.
2. Parasthesiae are admitted too commonly m
other conditions to be taken as characteristics of
l)ernicious anemia, although most cases of perni-
cious anemia, complain of them at one time or
another.
3. Glossitis — Under glossitis were included
those cases who presented to a greater or less de-
gree, a clean, glazed, fissured tongue. It should
be considered of negative value only. A dirty or
coated tongue is against the diagnosis of perni-
cious anemia.
4. Cord signs included diminution or loss of
the vibrator}' sense; two point discrimination
sense of position, or other sensations ; ataxia, or
the Babinski toe phenomena. Eighty per cent of
I>emicious anemia patients show some evidence
of postero-lateral cord involvement.
5. Color — The color index was plus in too
many of our doubtful cases. Until a more ac-
curate and practical instrument is devised to
determine the hemoglobin percentage, too mudi
importance should not be attached to a plus color
index unless the same is decidedly plus, one and
two-tenths or better.
6. Red cells of two and five-tenths million or
less : Cases seldom come to a hospital with the
symptomatolog}- o.f pernicious anemia, weakness,
dyspnoea, pallor, and associated symptoms with a
red cell count below two and five-tenths million,
unless their initial symptoms are of neurological
character.
7. Leucopenia is so constant in pernicious
anemia, one should regard with suspicion any
case with a leucocytosis.
8. Abnormal red cells — Our cases especially
Group IT show too high a percentage of abnormal
red blood cells. Too few of our reports refer to
the type of abnormal red blood cells, present.
iMinot considers as almost diagnostic large oval
macrocytes or megalocytes which are often poly-
chromatophilic.
9. Achylia — .So frequently is free hydrochloric
VoL. XII, No. 6]
Journal of Iowa State Medical Society
219
acid found absent in the Ewald test meal, in
other conditions, that its absence should be con-
sidered only of negative value. If free hydro-
chloric acid is found one should doubt the
possibility of pernicious anemia. !Minot says,
“the absence of free hydrochloric acid, may pre-
cede the other evidences of pernicious anemia by
years.” Of our cases, there were two in Group I,
who did have free Hcl. present, one is still alive
after two years, the other has not been heard
from. There were eight cases in Group II and
III, five are •still alive, two not heard from and
one dead. The one that died, had a red count of
over four million, a leucocytosis, a negative blood
smear, and a coated tongue. He died within one
month after leaving hospital.
10. Urobilin and Urobilinogen — These two
substances in excess in the urine and stools, are
found in any hemolytic process, certain diseases
of the liver, and cardiac decompensation. If not
found in excess, in a suspected case, it is evi-
dence against the diagnosis of pernicious anemia.
Sunni ARY
1. (9ur cases of pernicious anemia were di-
vided into three groups: definite, doubtful, and
very doubtful cases. The cases were classified
on a percentage basis, allowing a value of 10 per
cent to each of ten so-called diagnostic points.
Of Group I or the definite group, fifty-six of the
eighty-five cases are dead, twenty are alive, nine
have not been heard from. Of those dead, ten
were autopsied, the diagnosis was verified in all.
Of those that died after leaving the hospital, in
but one does the diagnosis seem questionable. Of
those alive, that have been heard from, nothing
in the replies to inquiry, would lead one to sus-
picion the diagnosis. Of those in Groups II and
III, forty-two cases in all, six are dead, twentv-
eight are alive and eight are not heard from. Of
the six dead, three were known to have died from
other courses. Of the twenty-eight alive, that
have been heard from, five have been fairly well
proven to have been mistakes in diagnosis. The
absence of a subsequent history of relapse or re-
mission in any of the others leave those cases
still in doubt.
2. Of the diagnostic points chosen five are
considered of distinct positive evidence, and five
contribute greatly to the diagnosis of pernicious
anemia because of their negative evidence. Of
positive value are: (a) histoiy of remissions, (b)
evidence of postero-lateral cord involvement, (c)
a red blood cell count below two and one-half
million, (dj a leucopenia, (e) abnormality of the
red blood cells. Of the negative points, that is:
factors that are against the diagnosis of perni-
cious anemia if absent are: (a) histoi'y of pa-
rasthesiie, (b) glossitis, (c) a plus color index,
(d) absence of free hydrochloric acid in the
Ewald test meal, and (e) the abnormal excretion
of urobilin and urobilinogen.
Discussion of Papers of Drs. McLaughlin and Rohner
Dr. Walter L. Bierring, Des Moines — I will ask
the indulgence of the chair to permit the presenta-
tion of a patient who illustrates an unusually long
remission. His present age is fifty-two years, by
oceupation a farmer. In this case the diagnosis of
pernicious anemia was made in 1915. The patient’s
first blood count was 1,450,000 red cells, 3800 leu-
cocytes— polymorphonuclears 42 per cent, lympho-
cytes 58 per cent, hemoglobin (Sahli) 56 per cent.
After a series of examinations covering a period of
thirty days he had his first blood transfusion, and
(luring the next four months two more transfusions
were given. In the following year his red cell count,
having previously gone up to nearly 3,000,000, again
dropped to 1,800,000. Then in 1918 the count began
to rise and it has so continued, and today the blood
e.xamination shows hemoglobin 80 per cent, red cells
4,790,000, leucocytes 7800, with a polymorphonuclear
percentage of 74, so that the blood count indicates a
distinct remission of improvement even to the point
of a better proportion of the wdiite cells than in the
original and more characteristic count. This man
farms 160 acres of land, and during the last two
years has clone most of the work himself. Besides
the three transfusions he has had some arsenic treat-
ment, mosth' in the shape of Fowler’s solution. In
the past three years he has had practically no treat-
ment and has not been here for any examination.
At present he has an excellent appetite, and no ap-
parent digestive disturbance, so it is fair to assume
that he has an adequate gastric secretion. He il-
lustrates a rather unusual remission of long stand-
ing. I also wish to present a gentleman w'hose his-
tory extends over a period one year longer, having
had his first diagnosis made seven years ago. He
came under our observation less than six years ago,
when his red cells were below one and one-half mil-
lion, with the characteristic leucopenia and other
phenomena of pernicious anemia. He w^as treated
for symptoms of colitis, mainh' by means of a care-
fully arranged diet, and remained a long time in the
hospital, during which time there was a gradual im-
provement in the anemia condition. During the last
four years he has had no treatment for his anemia.
Transfusions were not given. He has continued his
work as a minister and at present is on duty for full
time. His blood today show’s a hemoglobin of 85
per cent, red cells 4,550,000, with 6600 white cells, of
which 72 per cent are the polymorphonuclear type.
His present healthy appearance is a further illustra-
tion of a rather remarkable remission of improve-
ment. In the excellent papers that have been pre-
sented in this symposium, the importance of a re-
220
Journal of Iowa State Medical Society
[JuN-E, 1922
mission in diagnosis has been emphasized. I think
we might go still farther and refer to the wave-like
remissions that occur in a series of blood counts.
As we examine them several times a week or from
one week to the next there is a distinct wave-like
curve that is particularly characteristic of pernicious
anemia and may frequently distinguish it from the
severe anemias of the secondary type. As regards
the etiology of pernicious anemia special reference
has been given by Dr. ^IcLaughlin to the many con-
tributory causes, and it must be admitted that their
frequent definite association with this condition war-
rants considering them as distinct contributing fac-
tors. There are really onh' three well known causes
of pernicious anemia, these being the broad tape-
worm, pregnancy, and occasionally syphilis. In our
analysis of the improvement observed with different
forms of therapy, one should take into consideration
these cases in which there is a definite etiology', and
those in which the etiology is not so well defined. In
the cases due to the bothriocephalus latus, the pa-
tient naturally recovers when proper treatment is
instituted for the removal of the parasite. Prognosis
in the pernicious anemia of pregnancy is always bet-
ter than in any other form, and the remissions are
often permanent, or at least are maintained until the
next puerperal period. In cases of pernicious anemia
incident to pregnancy or the puerperal period, our
conception of treatment and its results should be
somewhat different from that in ordinary pernicious
anemia. That such good results are often obtained
with arsenical treatment may be distinctly in favor
of the spirochetal origin of pernicious anemia. As
regards the treatment of pernicious anemia, aside
from the systematic supervision of diet and general
hygienic care, so carefully considered in one of the
papers, I think we may safely say that there are only
two recognized treatments for this condition, viz;
1. Arsenic, which can be used either in the form of
Fowler's solution, cacodylate of sodium, or some
preparation of salvarsan. 2. Frequent blood trans-
fusions. I question very much whether in typical
pernicious anemia splenectomy has any real value.
As regards the benefit of transfusions, I think it
again should be emphasized that transfusions are of
little value, or at least very unsatisfactory, where
symptoms of spinal cord involvement are present.
Also in the very low counts, below a million red
cells, I question ver}- much whether transfusion is
always beneficial. The throwing into the circulation
of a large amount of good red blood where the
factors of safety and resistance are low, may pro-
duce a condition which frequently will be worse than
the state before. It seems to me that we should en-
tertain a different conception of this condition than
we have at present. We have studied it most faith-
fully not only from its etiologic and pathologic
standpoints, but also in its many interesting clinical
manifestations. I think we fail to recognize that
when pernicious anemia comes to us and can be
readily diagnosed, it is already a terminal condition.
It should be considered in the same light as arterio-
sclerosis, chronic nephritis, and a variety of other
chronic and terminal conditions. There should be
a way by which we might recognize pernicious
anemia before it has reached that stage of unusual
exhaustion of the blood-making structures that is so
resistant to treatment. In the careful routine exam-
inations of blood that are now made, in all such
examinations there comes a time when these early
and suggestive changes in the blood can be recog-
nized, and by a careful search for the causes of these
blood changes, possibly by removing foci of infec-
tion or to improve the diet and general mode of liv-
ing, it may be possible to prevent th% development
of pernicious anemia. At least we should assume the
attitude that it is a preventable condition, and thus
give to the entire problem a more encouraging
aspect.
Dr. W. E. Sanders, Des ^loines — There is just one
phase of this subject that I wish to graphically bring
before you, because we are frequenth' confronted
with the problem of splenectomy in the treatment of
pernicious anemia. I have been interested in hearing
the excellent papers that have been presented here
today, and have likewise been interested in review-
ing the literature as to the results which seem to
follow the different therapeutic measures to which
we have access for the treatment of pernicious
anemia. A therapeutic measure, in order to com-
mand our attention and confidence, should prolong
the life of the individual, make him more comfort-
able, or contribute to his earning capacity. If we
have any special procedure or measure which will do
that, it is worthy of our consideration. In 1913 the
first splenectomy for pernicious anemia was done in
Vienna. We are all hero worshipers and are very
apt to do things that emanate from certain sources.
It at once became the fad to do splenectomy in these
cases. In 191.3 I presented to this Society at its
meeting in Waterloo, thirty-seven cases collected
from the literature in which splenectomy had been
done for pernicious anemia with an operative mor-
tality of more than 20 per cent. In the paper pre-
sented by Dr. McLaughlin he has reviewed the liter-
ature and shown very excellent improvement in mor-
tality for this operation. For the charts presented
here I have taken 700 cases treated by tbe old med-
ical method as tabulated by Cabot in Osier’s ^lod-
ern ^Medicine and fifty cases splenectomized in the
^layo Clinic, and constructed a curve showing the
average annual mortality followed to their final out-
come. In passing, it might be said that Dr. Cabot
reports three cases out of a series of 1200, in which
he believes he has permanently cured the patient.
If you plot a curve showing the duration of the cases
which have been treated m.edically and surgically as
indicated by the red and blue lines, and the percent-
age of mortality which will follow each year, you
will find a striking parallelism between the medical
cases and the splenectomized cases from the Mayo
Clinic. The series from the Mayo Clinic, consisted
of fifty cases which had been splenectomized for
over three years when this report was made, and the
VoL. XII, No. 6]
Journal of Iowa State Medical Society
221
average duration of the disease before splenectomy
was about a year or something over a year. These
cases were selected with a view to the most favorable
results. Those with very pronounced cord lesions
cases were selected with a view to the most fav-
orable results. Those with very pronounced cord
lesions were not operated, those which showed
that they were getting worse were not oper-
ated. Most of these cases were transfused be-
fore the spleen was removed. At the end of one
year 41 per cent of the 700 patients whose cases
Cabot reports and followed to their termination,
were dead, while of the fifty splenectomized patients
42 per cent were dead. At the end of two years, 64
per cent of the splenectomized cases of the Mayo
Clinic were dead, and 62 per cent of the patients in
Cabot’s series were dead. At the end of three years,
78-f per cent of the splenectomized patients and 78
per cent of Cabot’s patients, were dead. At the end
of four years, 90 per cent of the splenectomize'd pa-
tients and 86-|- per cent of Cabot’s patients were
dead. Now, if we draw a curve showing the annual
mortality rate of the cases that were splenectomized,
we find that the results were very striking in that the
annual mortality rate is quite uniform. In the medical
cases, the mortality ranges from 34.6 per cent to 48
per cent a year, while in the surgical cases the mor-
tality rate ranges from 41 to 50 per cent a year. If you
plot a composite curve for the mortality, the medical
cases will show an average annual mortality rate of
41.15 per cent, and the splenectomized cases will
show an average annual mortality of 44 per cent.
So I am sure we shall be convinced that splenectomy
is not indicated in pernicious anemia.
Dr. George B. Crow, Burlington— Dr. McLaughlin
called attention to the association of hypochlorhy-
dria in the second stage of the disease, but in re-
ferring to the dietetic treatment he did not mention
the fact that the diet should be directed to the hypo-
chlorhydria. It is a very common observation that
these cases frequently develop diarrhoea of a putre-
factive type, undoubtedly due to the absence of hy-
drochloric acid. Therefore, the administration of hy-
drochloric acid to these patients is advisable, and
also in the presence of proteid putrefaction the ad-
ministration of a diet poor in proteids is of consider-
able importance. In regard to the relation of hypo-
chlorhydria to the cause of pernicious anemia, it has
been observed for a good many years that the two
were almost universally associated. Of how long
standing the hypochlorhydria has been before the
diagnosis of pernicious anemia is made, we do not
know. I happen to have a case which came to me
one year ago because of putrefactive diarrhoea, a
very intelligent man who gave the history of being
admitted to one of the leading hospitals of the East
about twenty years ago because of digestive dis-
turbances. He was told at that time that he had
achylia gastrica. During the past twenty years he
has had repeated attacks of diarrhoea, which he says,
were similar to the one he had when he came to me.
Of course, one case proves nothing, but I mention
it as a case of known achylia occurring twenty years
before the diagnosis of pernicious anemia was made,
and previous to this he had attacks of diarrhoea, pre-
sumably associated with achylia.
Dr. McLaughlin — From the statistics I have read
and also from the statistics Dr. Sanders has given
us, it would seem that splenectomy in pernicious
anemia is not indicated. However, I have too much
confidence in the report of such men as Dr. Percy
and Dr. Moynihan of Leeds, England, and of ob-
servers at the Mayo Clinic, to feel that I can be
dogmatic enough to say that splenectomy is not in-
dicated when recommended by such high authorities
The great difficulty we find in the treatment of per-
nicious anemia is in early diagnosis. I now have un-
der observation a man thirty-two years of age who
has visited the Mayo Clinic three times for observa-
tion, his case was not diagnosed pernicious anemia
by them. He has appeared at our laboratory for the
last three years for diagnosis of his anemic condi-
tion, and it has not yet been diagnosed pernicious
anemia. Still, he looks as if he had pernicious
anemia, and I think that eventually this diagnosis
will be made. There is so much variation in the
general course and symptoms of these cases that I
do not think any man is big enough to stand up and
say positively in these doubtful cases whether they
are, or they are not pernicious anemia, hence a de-
lay in proper treatment. I did not say that splen-
ectomy was a cure for pernicious anemia, although
in my own experience, I know of several cases that
have been greatly benefited; one in particular was
brought to Dr. Percy from the Battle Creek Sani-
tarium on a cot, practically moribund. He received
his stepladder transfusions, had a splenectomy, chol-
ecystectomy, and an appendectomy, and lived in my
neighborhood for six years afterwards, the greater
part of that time in fairly good health with compar-
atively few transfusions, until near the termination
of the case.
Dr. Rohner — Dr. Bierring spoke of three types of
pernicious anemia in which we know the cause:
Those associated with pregnancy, those due to syph-
ilis, and those due to the bothriocephalus latus.
They may be pernicious types of anemia, but are not
primary anemias. This paper represents a study of
primary anemias and not anemias of known cause.
The National Society for the Study and Correc-
tion of Speech Disorder will hold its annual meeting
as an allied association with the National Educa-
tion Association, that meets in Boston from July 3
to July 7, 1922. The Society will meet every after-
noon during the N. E. A. session. Each afternoon
will be taken up with formal papers by officers and
Massachusetts speech teachers. Then there will be
ten five minute papers open to general discussion.
There will be a demonstration with maps and charts
showing the progress of the American Movement for
Speech Correction from coast to coast.
222
Journal of Iowa State Medical Society
[June, 1922
THE CONTROL OF HEMORRHAGE IN
THE TONSIL OPERATION
Fred \V. Bailey, IM.S., IM.D., F.A.C.S.,
Cedar Rapids
A decade ago not a great deal of attention was
given to the control of hemorrhage and the con-
servation of blood in the tonsil operation. This
was prior to the perfection of the “suction ether
vapor” apparatus. Before the application of this
apparatus, if a general anesthetic was used, it was
necessary that the patient be deeply anesthetized
so that there might be as little gagging and vomit-
ing as possible, and so as to lessen the chance of
aspiration of blood, mucus, etc., into the trachea
and lungs. The operation had necessarily to be
hurried, a clear view of the field was not possible,
and patients were sent from the operating room
while still bleeding. It was not unusual, and in
fact rather the rule, for the patient to spit and
vomit blood for the first twelve to twenty-four
hours after the operation. One often heard it
remarked that “tonsil cases always bleed more or
less” and that “it probably did no harm.”
In local anesthesia then as it is now the rule
was to use some sort of drug such as adrenalin
combined with the local anesthetic to prevent
bleeding at the time of the operation and trust to
luck and providence that there would be no trou-
ble due to reactionary hemorrhage after the ton-
sils were out, and the effect of the drug wore
away.
Since the advent of the “ether suction” ap-
paratus and since the gradual improvement of
the tonsil operation technique, much more atten-
tion is given to the control of bleeding and the
conservation of blood. In spite of this fact it
seems to me that generally speaking, the average
larvngologist is not nearly as careful of the loss
of blood as he should be.
Removal of the tonsil is a common operative
procedure. In fact the average eye, ear, nose and
throat surgeon does perhaps five or more times
as many tonsil operations as all of his other oper-
ations put together. I would venture to say in
most hospitals there are more tonsil operations
than any other single class of operations.
There are various and numerous methods de-
vised and practiced for the removal of the tonsil.
The aim of all are ultimately the same — that is —
the complete removal of the tonsil with its so-
called capsule from its bed, with as little trauma-
tism of the adjacent tissue, and with as little
•Presented before the Seventieth Annual Session. Iowa . State
Medical Society, Des Moines, Iowa, May 11. 12, 13, 1921.
Section Ophthalmology, Otology and Rhino-Laryngology.
shock and discomfort to the patient as possible.
It is a purely surgical procedure and should be
treated as such. The operation leaves an open
wound no matter what method of removal is em-
ployed. The wound is not only open but is mov-
able. Every time the patient talks, swallows,
vomits, coughs, etc., the wound moves and the
tissues are put on tension.
Thus the open and movable tonsil wound can-
not be treated as an ordinary closed surgical
wound, but necessarily requires some method of
treatment that no matter what may happen in the
way of coughing, gagging, vomiting, etc., the
wound remains safe from bleeding.
It can hardly be denied that the less blood a
patient loses in any operation the better chance
thejDatient has for a speedy recovery, and that
the less blood he loses at the time of the operation
the better he can withstand reactionary or sec-
ondary hemorrhages, should he be unfortunate
enough to have this complication. It is also true
that the more blood a patient loses the more de-
lay there is in his coagulation time, and his vi-
tality and vital resistance decreases with the
amount of blood lost.
The tonsil operation is taken much more se-
riously today than it was a few years ago. It
is an operation which people and also the laryn-
gologist .still often speak of too lightly. This
idea is entirely wrong. The patient who has his
tonsils removed suffers more pain and discomfort
than the average case that is operated on for ap-
pendectomy. Of course there are exceptions in
both cases, but I would venture to say this is
the rule. A great deal has been said and written
on the tonsil question and at first thought the
subject seems to be overdone, but nevertheless
there is still much to be learned about the tonsil
operation and its various phases.
The blood supply of the tonsil is generally quite
well known. All the arteries supplying it come
either directly or indirectly from the external
carotid. They pierce the so-called capsule of the
tonsil and enter its substance. Thus when the
tonsil is removed from its bed the arteries and
vessels must be cut or severed according to the
method used in the enucleation. Wherever there
is a vessel cut or severed there is a point which
may bleed.
In the year 1914 I encountered a rather severe
tonsil hemorrhage at the time of operation, which
was finally controlled with considerable difficulty
by suturing the bleeding point, using a small
curved needle, fine plain cat gut and an ordinaiA'
needle holder. After this experience I began at
once to search for a method of controlling hemor-
VoL. XII, Xo. 61
Journal of Iowa State Medical Society
223
rhage which would conserve all the blood possi-
ble at the time of the operation and would he
effective in case of reactionary or secondary
hemorrhage. I tried pressure alone, and com-
bined witlj various chemicals such as adrenalin,
tincture of iron, iodine and alcohol and others.
I tried grasping the bleeding point with a hemo-
stat allowing the hemostat to remain a few min-
utes. I tried picking up the bleeding point and
then crushing the tissue with an angiotribe. I
also tried coagulose locally. I then tried suturing
the bleeding points in all cases.
This last procedure has proven the most sat-
isfactory, both as to controlling the hemorrhage,
the conservation of blood, a minimum traumatism
to the tissues and a minimum discomfort to the
patient. It also gave a clearer looking throat
after the operation and the healing time was con-
siderably shortened.
The method used in suturing the bleeding
points is a slight modification of the one de-
vised by Davis. I use an extra long Elliott’s pick
up to grasp the bleeding point and pass a suture
of Xo. 0 plain cat gut on each side of the vessel
and then tie not very tight. I use an Ingersol
tonsil needle not too sharp. I have never found
a bleeding point in any tonsil fossa which could
not be readily reached and ligated with this nee-
dle. There are many needles devised for this
purpose, I have devised some myself. Some are
made with right angle points and made for right
and left side. I have tried many of them but the
Ingersol has proven most satisfactory'.
I have now a record of a series of .3025 tonsil
operations in which the bleeding points were con-
trolled at the time of the operation by the suture
method. In this series of cases I have had forty
reactionary hemorrhages — or one in about every
seventy-five cases, and three secondary hemor-
rhages, or about one in a 1000. In the case of
reactionary or secondary' hemorrhage, the patient
was taken to the operating room and with a light
anesthetic the bleeding points were found and
sutured.
I think as a rule, reactionary hemorrhages in
my cases were due mostly to carelessness and
haste in not making sure the bleeding was stopped
entirely before the patient was sent from the
operation, or from using cat' gut which was too
large and became untied, when the patient gagged.
Some cases were evidently due to the fact that
the suture did not pass around the vessel, but to
one side of it, and thus exerted enough pressure
to stop the bleeding for a little time.
Wondering just what other laryngologists in
the country were doing along the line of the con-
trol of hemorrhage in the tonsil operation, I sent
out the following questionnaire to 400 laryn-
gologists, all members of the American College
of Surgeons :
1. How do you control hemorrhage, either
sqvere or ordinary, at the time of operation?
2. Do you do a coagulation test before opera-
tion in any or all cases ?
3. How do you control post-operative hemor-
1‘hage ?
4. Have you ever had a patient die from hem-
orrhage following tonsil operation?
To this questionnaire I received, up to the time
of writing this paper, 350 replies. I have gone
over the answers very carefully and have classi-
fied the replies as given below. The number
after each method mentioned, indicates the num-
ber of times that certain method was mentioned.
Answers to question number one (How do you
control hemorrhage, either severe or ordinary,
at the time of operation?), elicited the following
replies. The numbers indicate the number of
times the method was mentioned. Pressure, 217;
hemostats, 117; ligature, 129; sutures, 46; suture
pillars, 46 ; thermboplastion, 41 ; suture sponge in
fossa, 18; coagulose, 20; tannic acid, 10; mor-
phine, 19; petuturin, 4; vaseline sponges, 3; elec-
tric cantury, 3 ; turpentine, 2 ; peroxide of hydro-
gen, 9 ; powdered alum, 3 ; iodine tincture, 5 ;
Michels clips, 7; adrenalin, 17; silver nitrate so-
lution, 4; tincture of benzoin, 5; jMonsel’s solu-
tion, 5 ; hot saline, 2 ; tonsil clamps, 8 ; acetanalid
and alcohol, 50 per cent; bismuth, ergot, alcohol,
zinc sulphate, gelatine, permanganate of potash
solution, neosalvarsan, mercuiy, lemon juice, rab-
bit serum, hemostats left on bleeding points one
to twelve hours, holding enucleated tonsil in
fossa for few minutes, injecting two or three ton-
sil syringes of pure hydrogen peroxide in post-
nasal space, and finally, scraping tonsil fossa with
finger nail left sharp for that purpose. In ad-
dition to this, eight replied that they did not at-
tempt to control hemorrhage and ten reported
that they never had any hemorrhage. Eight used
pressure only; thirty used ligatures and twenty-
seven used sutures as a routine procedure.
The fact that forty methods of controlling hem-
orrhage resulting from the removal of the tonsils,
are used by only 350 operators leads one to con-
clude that this phase of the operation is a long
way from being standardized. There seems how-
ever to be a tendency to ligation and suture, but
most of the operators appear to be quite well sat-
isfied with their own methods.
Crushing the base of the fossa certainly causes
undue traumatism. Suturing the pillars or su-
224
Journal of Iowa State Medical Society
[June, 1922
luring a sponge in the tonsillar fossa, must sub-
ject the patient to most undue discomfort, when
attempting to swallow or when vomiting or gag-
ging. Styptics cause undue sloughing and in-
crease the probability of secondary hemorrhage ;
ligatures, although effective at the time of appli-
cation are likely and in fact very often slip off
when the patient swallows, etc. A suture prop-
erly applied cannot slip off, causes little or no
extra discomfort, is absolutely effective and cer-
tainly more scientific than any of the other meth-
ods mentioned.
Answers to question number two (Do you do
a coagulation test before operation in any or all
cases?), brought the following replies: Always
use the coagulation test, 75 ; never use the coag-
ulation test, 60; sometimes use the coagulation
test, 215. The general opinion seemed to be that
the coagulation test as a routine, might be of
value to the laboratory findings in the case in
question, but that a careful family history of the
patient was much more important than a coag-
ulation test. True hemophilia is rare, but must
always be considered; anemic patients are more
apt to bleed than those who are full blooded and
plethoric. Patients do not bleed as a rule be-
cause the blood does not clot, but because the end
of the vessel remains open.
Answers to question number three (How do
you control post-operative hemorrhages?), shows
that the secondary hemorrhage is rather rare and
when it does occur is not very severe. It is
often confused with reactionary hemorrhage.
Secondary hemorrhage was reported to have oc-
curred as late as twenty-one days after the re-
moval and there were four cases of ligature of
the common carotid to control this class of hem-
orrhages reported.
Answers to question number four (Have you
ever had a patient die from hemorrhage follow-
ing a tonsil operation?), revealed the fact that
out of 350 operators, 27 report a death from hem-
orrhage following the removal of the tonsils.
This means that out of 350 operators one in every
13 has had a death from hemorrhage. It is true,
that these operators reported all the way from 50C'
to 20,000 tonsil operations each, and conse-
quently, the ratio of death from hemorrhage to
the number of operations performed is small in-
deed. But when one thinks how often he him-
self performs this operation and that as men-
tioned above, one operator in thirteen has had a
death from hemorrhage, it comes pretty close
home after all.
In conclusion, will say that it seems to me
that death following hemorrhages from tonsil
operations seems inexcusable, and is probably due
not only to the fact that the hemorrhage was not
stopped, but to the fact that the nurse who was
in charge failed to notice that the patient was
bleeding. A patient, especially a child, will often
lie on its back and swallow blood and get almost
exsanguinated before it is noticed that the child
is bleeding. Patients, especially children, should
always be turned on their stomach until there is
reason to believe that there is no hemorrhage.
Often a life might have been saved if this simple
procedure had been followed out.
Acknowledgments are due to all the doctois
w'ho so carefully and promptly filled in and re-
turned the cjuestionnaire, and to Dr. J. E. Stans-
bury, who so carefully and painstakingly recorded
my series of cases.
Suite 309-11, Security Building
SO^IE DETER^HXIXG FACTORS IX
' XASAL SIXUS DISEASES*
G. F. Harkness, M.S., ?\I.D., F.A.C.S.,
Davenport
It is not my intention to present in orderly and
scientific array the indications pro and con of
nasal accessory sinus diseases, but simply nota-
tions that have come to my mind in the routine
examination of patients suspected of having such
diseases, or in those presenting clinical evidence
of the same. The paths of scientific study should
always converge to the point of practical applica-
tion for the relief of the patient. It is what we
do or do not do for our patients that is really the
all-important question.
I do not know whether it is a sign of premature
senility, but I confess to a mythical companion
and patient, wdiom I may call Smith wdio keeps
me company in my reading. Smith accepts any
patholog}' with which I may wish to inflict upon
him, permits any operation even with fatal term-
ination only to represent himself again and again
as a willing victim. This little game of visualiz-
ing one’s reading and then placing the conclusions
reached by the side of the actual patient is really
of considerable practical help.
The treatment of accessor}- sinus diseases, I am
sure, is to many of us far from satisfactory, and
the end results often disappointing. Here I am
reminded that my patient Smith, who is really
a very intelligent fellow, is constantly rej^eating
two statements ; first, “Doctor, put yourself in
my place and if what you propose to do is what
‘Presented before the Seventieth Annua! Session. Iowa State
Medical Society. Des Moines. Iowa, May 11. 12, 13. 1921,
Section Ophthalmology, Otology and Rhino-Laryngology.
VoL. XII, Xo. 6 1
louKNAL OF Iowa State Medical Society
225
you would have done, then go ahead;” and sec-
ondly, “Doctor, I am complaining of certain symp-
toms. What I want is relief from these symp-
toms, and I am not jiarticularly interested in the
architectural contour of my nasal cavities after
operation. Kindly limit your operative procedure
to the extent of incomplete relief necessitating a
second operation as against doing your work so
thoroughly and extensively that I may find my-
self relieved of present complaints, but suffering
from other equally unpleasant symptoms from
which there is no relief.”
There is. and should be, a sane pathway be-
tween the so-called “nibbling” rhinologist and the
ultra radical enthusiast.
The roll of accessorv sinuses as foci of distant
infections has immensely increased their import-
ance and likewise our responsibilities. In acute
cases our problem is certainly one of drainage
with which we should be content, and I believe
the problem of drainage is far more important in
chronic cases than many operators will concede.
.\bsence of headache means nothing, but its
presence with other symptoms is important. Ir-
regular periodicity, increase in certain posture.-;
and definite location of a head pain as distin-
guished from a headache, brings sinus disease to
one’s mind together with the fact that the location
of this head pain does not of necessity have to be
located in the immediate neighborhood of the
sinus involved.
Tenderness is not of much value as a guide, ex-
cept as perhaps, in the case of the frontals, and
then it is the comparative tenderness of one side
to the other that is important.
Absence of pus in the nasal chambers means
nothing, and its presence as an indicator of sinus
disease attains its greatest value when it reap-
pears at the same spot shortly after having been
removed. It does not indicate the pathology pres-
ent and in character only partially aids us in es-
timating the ability of the sinuses to drain them-
selves. Skillern states that cacosmia when present
is almost pathognomonic of accessory sinus dis-
ease. Symptoms, however, entirely subjective
must be received with some reservations.
Changes in the nasal mucosa are important. In
the acute cases they are more general while in
the chronic cases hypertrophies are generally near
where the exudate first makes its appearance.
Variations in the septum, however, may have
brought about changes prior to the contracting of
accessory sinus disease so that the picture is ma-
terially changed in the chronic cases.
In considering the presence of polypi, one does
not necessarily have to debate the question as to
whether polypi precede or are a secpience of bone
disease. There is, of course, no question as to
the desirability of eradicating diseased tissue in
the neighborhood of the origin of the polyps, yet
in the presence of polyjwid degeneration con-
serve all the normal tissue possible. The large
solitary choanal polyp we can well afford to treat
most conservatively, that is pulling out by the
snare and without other clinical evidence of sinus
disease simply await developments. .Sub-acute
larymgitis and pharyngitis, bronchial symptoms
and asthma always demand careful sinus investi-
gation.
The importance of the accessory sinuses in
children has again been most forcibly brought to
our attention by the work performed under the
direction of Dr. Dean in his department at the
.State University, working in conjunction with
the department of pediatrics.
There is the personal equation to be considered.
Symptoms that in one individual justify operative
measures would not be justified in another to
whom these symptoms cause very little annoy-
ance. Change of climate no doubt often causes
an entire disappearance of symptoms and clinical
evidence of chronic sinusitis. The influence of
climatic conditions is further substantiated by the
fact that rhinologists working in a high and dry
altitude report the relief from operative meas-
ures to be more permanent.
I assume without going into details that our
routine examinations are very similar. These
include, of course, the principal and secondary
complaints of the patient, previous general health,
the presence or absence of fever, and an accom-
panying eye examination. A differential blood
count and Wassermann is desirable in all chronic
cases.
The size of the air passages is to be kept in
mind, and the position of the nasal septum if too
often disregarded in the presence of clinical evi-
dence of sinusitis.
The use of the trans-illuminator has a definite
place and as regards type I have found after try-
ing many that the small ophthalmoscopic lamp is
as satisfactory as any. Its use is, of course, lim-
ited to the frontals and the antra, the latter by
the Briggs method, and the findings of value only
in comparing one side with the other.
I do enter the adult antrum of Highmore with
a trocar without previous radiographic study but
do not feel that other operative investigations are
so justified. While the roentgenograph does not
tell us the pathologv" present it enlightens us as to
anatomy and the presence of an abnormal condi-
tion of the interior of the sinus cavity. By it we
226
Journal of Iowa State Medical Society
[June, 1922
can generally establish the absence of a frontal
sinus. To me it has been most unsatisfactory m
posterior ethmoiditis. Unusually clear ethmoids
do not signify absence of patholog}’, but may
mean reabsorption of bone and a thinning of
membranes in an old chronic ethmoiditis. Rad-
iographs from but one angle are incomplete in
the information imparted and the more general
use of stereoscopic negatives will enhance the
value of x-ray findings.
Returning to the localization of pus after tran-
sillumination and • radiographic examination, I
have by preference, been using a sharp Pierce
trocar instead of the diagnostic needle in the
maxillary antrum. Absence of return flow may
mean the end of the trocar against the antrum
wall ; secondly, the presence of polypoid growths
within the cavity or, thirdly a blocking of the
natural ostium or ostea. It arouses our suspic-
ions as to antrum disease but does not establish
the same. The return of pus means antrum disease
or the antrum acting as a receptacle for pus from
some of the upper sinuses. Irrigation of the an-
trum is often misleading. The return of a clear
fluid does not mean the absence of pus or after
pus has been returned the appearance of clear
fluid does not mean that there is ho pus left in
the antrum. I have found that after the above
test that by connecting the canula with a small
5 c.c. syringe and then aspirating that one can
frequently obtain pus from the cavity.
The sense of touch as transmitted from the end
of a canula or large silver probe is of value in
gi^•ing some idea as to the character of the lining
membrane. Pus in the middle meatus an hour
after thorough cleansing the antrum gives fair
assurance of involvemet of some of the upper
sinuses. Packing off of the upper sinuses and
then finding pus in the antrum has been unsatis-
factory to me as positive indication of antrum
disease. Pus in the antrum demands radiographic
study of the teeth. Whether in antrum disease
apical abscesses and ^periostitis are secondary to
the antrum disease or vice versa need not concern
us. I believe the fact remains of their associa-
tion and of the relief afforded the antrum by
their removal and that often in spite of antrum
operation relief will not be obtained until the af-
fected teeth have been removed. Antrum dis-
ease demands drainage more than anything else.
Sounding of the frontal sinuses is very often
unsatisfactor}", even after infracting the middle
turbinate. The existence of frontal sinus disease
without that of the anterior ethmoidal cells is a
rarity, and its establishment by means of a plug in
the hiatus has been to me practically a failure.
The use of the naso-pharyngoscope I have lim-
ited to investigating the sphenoidal ostia and the
posterior ethmoidal cells. Diagnosing sphenoidi-
tis by this means, simply from the presence of
some slightly engorged vessels in the neighbor-
hood of the ostia has been unsatisfacton', and in
the presence of pus the differentiation between
sphenoiditis and posterior ethmoiditis has been
practically impossible. It does establish the fact
of disease of the two cavities and since they are
both generally involved, our course is not ma-
terially affected once infection in this locality is
established. Irrigation of the sphenoidal sinus
prior to any operative measures I have found
often to be impossible on account of anatomical
variations.
M hen these cavities, so often disregard any
anatomical standard, it is impossible to state
standard rules as to procedure, but we all have in
our own minds certain flexible rules which we
individually follow with our patients, and a dis-
cussion of those is the only justification for this
paper.
Let us presume that our hypothetical i\Ir. Smith
presents himself following an acute coryza of
some days previous, complaining of pain of a
type rather characteristic of sinus involvement.
He has a slight fever but is about his business
and will not consider himself a bed patient. Pre-
vious history is negative, transillumination is in-
definite, the nasal mucosa is still markedly in-
flamed and pus is seen without any definite loca-
tion, but does reappear in a short time under-
neath the middle turbinate. Smith is busy, can-
not see why radiographic plates are necessary
since all he wants is some relief. Our procedure
is to meet his demands by cocainization, without
adrenalin, and suction by the Coffin apparatus,
preceded if there is a crowding together of the
middle turbinal and bulla, by infraction of the
former towards the midline. Small doses of
aspirin and phenacetine supplement the office
treatment. Relief is obtained, nature assumes the
upper hand, resolution takes place. Smith is satis-
fied and we are content with a more or less un-
scientific diagnosis. I am not entirely satisfied
as to the rational of suction and the so-called
vaccuum headache, but the fact remains that re-
lief is often obtained whether pus is withdrawn
by the suction or not.
Again, let us presume that Smith returns and
has not obtained the relief desired, or that it is his
first visit and that transillumination (Briggs)
shows a darker antrum on one side. He has no-
ticed that a large amount of discharge is present
in the morning on arising, the line of pus under
VoL. XII, No. 6]
Journal of Iowa State ]\Iedical Society
227
the middle turbinate may or may not reappear
shortly after removal. The pain is largely supra
orbital. We now use the trocar in the inferior
meatus followed by irrigation. Positive findings
of pus demand daily irrigation, the continuation
of the suction treatment as long as pus is seen in
the two upper meati. Lavage of the antrum is
not complete until the aspirated fluid is clear. If
we have difficulty with the return flow, or the
opening tends to close it is easily enlarged with
the rasp, punches being more difficult at times to
insert under the inferior turbinate.
The odor present at the initial opening is of no
particular prognostic significance.
Following this conservative treatment. Smith
has remained at work, sleeplessness has left him,
and in fact, he feels back to normal, but the an-
trum discharge has lessened up to a certain point
and then remained stationary. He has undergone
a dental examination with negative findings. We
are satisfied that his antrum is the only cavity in-
volved. After using various solutions for irriga-
tions, we feel that all are wanting without free
drainage and that with free drainage it does not
make very much difference what you use except
that all solutions are of themselves more or less
irritating to the antra-mucosa, and with our pa-
tient without symptoms, except a small persistent
discharge, we simply give him a rest, have him
come back in a week or ten days, lavage the an -
trum with negative ' findings and realize that
further treatment would have impeded rather
than aided nature. Maxillary sinus disease of
dental origin I believe is better treated after the
extraction of the offending teeth and the curet-
ting of softened bone, through the inferior meatus
than through the alveolar process.
Chronic maxillary sinusitis demands more rad-
ical measures, but considering the various path-
ological conditions found within the sinus and
the variations in anatomical conformation of the
nasal chamber, I do not believe there is any one
operation that is suited to all cases. Drainage is
still the preeminent factor. Only part of the
mucous lining showing positive degeneration,
polypoid or otherwise, should be curretted. De-
nudation of the entire lining membrane of the
cavity precludes the possibility of its ever regain-
ing a normal membrane. In order to accomplish
this it is necessary that the cavity be inspected by
the eye, and such inspection and accomplishmeni
is difficult in the presence of much blood. There-
fore we have adopted two courses, one for cases
under local and one for cases under general an-
esthesia, because the control of hemorrhage is
more difficult under general anesthesia, the su-
prarenal extracts here seeming to have little ef-
fect. Lhider local anesthesia the Dahmer method
is rejected because it first demands the removal
of a large amount of the inferior turbinate. We
prefer to commence the operation according to
Skillern’s pre-turbinal operation, this affording
an inspection of the sinus partly by the eye and
partly by the naso-pharyngoscope. If the path-
ology revealed is not particularly marked we are
content, but since the opening made by this opera-
tion has a decided tendency to close before we are
ready for it to do so and if there is much degen-
eration present we then change the operation to
a Canfield and feel that while the sub-mucous re-
section of part of the inferior turbinate is diffi-
cult, it is much better than sacrificing the mucous
membrane. In fact, with a small nasal chamber
or a large turbinate occupying more than its
rightful share of the nasal cavity, this sub-
mucous resection is an added advantage to the
patient. W’e use a loose pack for forty-eight
hours and do not favor continued packing.
Twenty per cent silver nitrate solution is applied
to the walls of the cavity before the pack is in-
serted. Under general anesthesia, we prefer to
operate first through the canine fossa following
the Caldwell-Luc technique, this affording an in-
spection of the sinus and the removal of the de-
generated tissue and part of the inner bony wall.
Now leaving this operative field in the canine
fossa we do a pre-turbinal operation or Canfield
as indicated under the procedure, under local an-
esthesia limiting the distance outward from the
crista piriformis according to the amount of bone
excised when opening through the canine foss.i.
We prefer to leave a bridge of bone rather than
convert the operation into a Denker.
Time does not permit a tabulation of symptoms
of frontal sinus conditions. One must always
bear in mind that the interior of these cavities
does not normally always present smooth unin-
terrupted walls, but besides varying greatly in ex-
tent, have irregularities, partial septa and projec-
tions. The difficulties presented in the way of
probing I have found even greater than ordinarily
stated. There is no definite angle for the probe,
and the probing should be without force or dis-
continued.
When our patient Smith presents himself with
what we believe to be an acute frontal sinusitis
there are several points I tiy to keep in mind.
First, the serious complications from acute fron-
tal sinusitis are ver}' rare and that the chances or
such complications may be enhanced rather than-
diminished by an undue amount of instrumenta-
tion. Secondly, the problem to be solved in the
228
Journal of Iowa State Medical Society
[June, 1922
beginning stages is areation and later drainage of
the cavity. \Vhile fonnerly an attempt was made
to accomplish an irrigation of the cavity we now
largely dispense with it. Our recpiest for rest in
bed and the opportunity for rapid elimination by
means of sweats and through the alimentary
canal is generally disregarded unless the pain is
of a severe type. We are content or perhaps
forced to be content in the practical handling of
these cases which do not present manifest com-
plications with the shrinking of the tissues by
means of cocaine followed by the use of suction.
Preceding the suction the middle turbinate is in-
fracted towards the inidhne and if the symptoms
are not relieved the removal of the anterior end
of the middle turbinate follows. The combina-
tion of aspirin and phenacetine to relieve pain, a
course of calomel, and finally the drinking of
30 to -10 grains of sodium bicarbonate dissolved
in a glass of water ever}' four hours for the alka-
linizing effect constitute our regular internal
medication.
Knowing that chronic inflammation of the
frontals are sequelte of acute inflammations and
that very rarely is the condition found without an
involvement of the ethmoids, the fact remains
that chronic though the condition may be, the
great causative factors to be eliminated are the
conditions that interfere with the drainage. The
correction of a deflected nasal septum is too often
neglected. The many external frontal operations of
a few vears past seems to me rather a sad com-
mentary on the credulity of the medical profes-
sion. Radical external operations do not give
the patients 100 per cent cures and entail a defin-
ite surgical risk to life. Notwithstanding expres-
sions to the contraiy, a comparison of the transil-
lumination of the two frontals has some value,
particularly when corroborated by the radio -
graphic plate. Further the x-ray, while not re-
vealing the type of pathology, has been one of our
greatest boons in outlining the anatomy of these
cavities.
Headache as met with now may be most any
kind of headache. Tenderness has not the diag-
nostic value it possesses in acute cases. Never
are we to diagnose a chronic frontal sinusitis
without an exploratoiy investigation by needle
or trocar, of the maxillary antrum.
Scanty secretions with continued severe symp-
toms generally mean more advanced changes,
while profuse discharge with relief generally
more limited patholog}'. Considering the one
narrow outlet from the sinus we bend our efforts
to maintain its patency by the correction of an-
atomical variations, septal, turbinal and eth-
moidal. Erery effort is made to enter the sinus
by probe and canula. In the enlargement of the
duct the use of the rasp has to me proved most
satisfactoi'y. It works from behind forward and
to work in the opposite direction or simply up-
wards is disregarding the great respect that
should be shown the roof of the nasal chamber
and the posterior wall of the frontal cavity. So
our patient, knowing his hazards, rejects an ex-
ternal operation even though there continues to
be some fetid discharge, and we do not partic-
ularly urge it unless his headaches remain or re-
cur in severe form or he suffers from other con-
ditions, possibly focal in origin, which incapaci-
tates him at times. There are, of course, absolute
indications for external operations.
The ethmoid labyrinth with no definite num-
ber of cells and with no rule as to position or size
makes it almost impossible to formulate any
definite rules of procedure. Yet here really lie'=:
the crux of our surgical sinus work. Our prob-
lem has not changed. It is one of drainage. Our
coryzas must be largely acute ethmoidites catar-
rhal or suppurative with more or less of an ex-
tension to the other sinuses. Nature brings about
resolution and the more one studies his anatomv
the more one marvels at nature’s capabilities.
Skillern in his recent article making a plea fo"
conser^'atism first assumes that the middle tur-
binate is radically removed before adopting his
conservative course. He lays down the dictum
of tracing the pathology to its source at the same
time emphasizing the necessity of drainage. Sec-
ondaiy operation with the loss of landmarks and
the formation of fibrous tissue following the first
operation is difficult and it seems to me that we
are still looking for our Moses who is not going
to lead out of the ethmoid labyrinth but into ir
and show us just how and when to reach the
sources of infection with the least sacrifice of
normal nasal mucosa.
Chronic hyperplastic ethmoiditis without visi-
ble polypi is often baffling. Infracting the tur-
binate may not reveal it. The justification of
operative interference is established often only
from the symptomatolog}', headache, anosmia,
orbital symptoms, asthma, bronchitis and phaiyn-
geal irritation. Continuous “colds” should arouse
our suspicions. Headaches are usually rather
constant while in suppurative conditions they de-
pend largely upon the damming back or inclosing
of the pus.
Be the condition hyperplastic or be it suppura-
tive we have in a general way been guided to
follow two pathways depending on the size of the
nasal chamber. Drainage being our cardinal
VoL. XII, No. 6]
Journal of Iowa State IMedical Society
229
point, if the nasal chamber is narrowed to any
definite extent by a deflected septum that re-
ceives our first consideration. Having had or
obtained a broad nasal chamber, attention is
turned to the anterior end of the middle turbinate
and if it contains as it so often does a large cell
this is opened by hook or forceps, curetted and
then crushed together. If the middle turbinate
stills appears to be obstructive the anterior end is
removed. With our wide chamber the middle
turbinate can be infracted and by curette and
biting forceps we enter the bulla and ethmoidal
labyrinth, breaking down the cells seen to be in-
fected. We know that all cells are not reached,
but we do feel that we have facilitated drainage
with the least sacrifice of nasal mucosa and that
if secondary operations become necessary there
has not been an undue obliteration of landmarks.
Hyperplastic ethmoiditis with polypi formation
often yield to this treatment and where headache
has been most prominent symptom the patient ob-
tains the relief for which he came to us.
\Yith the narrow nasal chamber and with the
middle turbinal closely applied over the ethmoids
or with the broader nasal chamber when post
nasal examination by the naso-pharyngoscope es-
tablishes a predominating or marked infection of
the posterior ethmoidal cells, the immediate sacri-
ficing of the entire middle turbinate bone is in-
dicated limiting the curettage to those cells which
show infection.
The fact remains, however, that the ethmoidal
labyrinth still presents a problem which has not
been satisfactorily.
When we consider the sphenoidal sinus whose
thin walls are associated above with the optic
nerves and the pituitary body and externally with
the cavernous sinus and the internal carotid ar-
tery and which by over reabsorption may extend
into the lesser wings of the sphenoid, into the
pterygoid processes and into the basilar process
of the occipital bone, we can indeed acclaim with
the old professor of anatomy who held the bone
aloft and said, “The sphenoid bone, d the
sphenoid bone.”
It seems strange that with its ostium far above
the most dependent part of the cavity that it
rarely suffers an acute inflammation per se suf-
ficient to w>arrant interference in an operative
way. Headaches radiating to the parietal and
temporal region or to the ears and with tender-
ness of the eye balls is rather significant. Head-
ache in these chronic cases may not be prominent
at all.
We are all familiar with the means of differen-
tial diagnosis as ordinarily outlined and the sig-
nificance of pharyngitis sicca, pharyngitis lat-
eralis, post pasal accumulation i)articularly in the
morning, ocular symptoms especially scintillat-
ing scotoma and enlargement of the blind spot,
laryngeal symptoms, hoarseness and catarrhal in-
flammation about the arytenoids.
Nowhere do we have impressed upon our
minds more the ini]:)ortance of sinus drainage as
here for the chronic cases as long as this is main-
tained generally go along for years without any
apparent ill-effects except the local irritation.
Reinfection after operation frequently occurs
with no particular ill-effects, providing there is
no obstruction offered to the purulent discharge.
Contrasted to these cases are the severity of
symptoms when infection exists with obstruction
and procrastination with meningitic or ophthalmic
symptoms may be fatal.
We must ha\e some general rule to follow •
when our patient sus])ected of sphenoiditis pre-
sents himself. First there is almost always as-
sociated with chronic sphenoiditis a posterior
ethmoiditis. Secondly, due to anatomical varia-
tions sounding will be unsuccessful in the ma-
jority of cases. Thirdly, when we have symp-
toms which draw our attention to the ^sphenoid
and in addition establish the presence of pus near
the ostia by means of the mirror or naso-pharyn-
goscope or by the latter see that this area shows a
very marked congestion I feel one is justified in
adopting this procedure. First the correction of
septal deflections interfering with complete diag-
nosis. Secondly, because of the close association
of sphenoiditis and posterio ethmoiditis it is not
essential spend a great deal of time trying to dif-
ferentiate between the two because the means of
establishing a positive diagnosis and the operative
measures permissible are almost one and the
.same. Sacrifice the posterior half of the middle
turbinate the ostium is then easy of access and
without difficulty enlarged down to the floor of
the sinus. Here ends the operative procedure.
Do not curette the sphenoidal sinus. If polypi
present themselves they may be pulled out but be
content with facilitating drainage. If the opening
tends to close it can be easily enlarged again, and
local treatment to the sinus mucosa continued.
Only in those cases presenting serious complica-
tions is the radical sphenoid operation to be per-
formed. I have never done this through the
maxillary antrum, for it seems to me that what
we can do, can be performed by the nasal route.
Multiple sinusitis demands the same reasoning
that do infections of the individual sinuses.
In concluding my one thought is that in the
surgical treatment of our sinus cases the cardinal
230
Journal of Iowa State Medical Society [Tl'xe, 1922
principle to be kept in mind is the aiding of
nature by tree drainage and this alone is very
often all sufficient.
COMBINED ANESTHESIA
Charles Ryan, i\I.D., E.A.C.S., Des IMoines
(Continued from ^lay Issue, 1922)
Discussion
Dr. C. R. Armentrout, Keokuk — The subject of
combined anesthesia is one that is of a very
great interest to every surgeon. Until recently
combined anesthesia to most of us meant the
use of nitrous oxid, oxygen and ether. I have
used this anesthesia in nearly 300 cases, and am
pleased to say that my observations rvere very close
to those of Dr. Ryan. Some of the principal points
• of interest to me were these: It shortens the time
before the patient goes under the anesthesia. With
ether it is always at least ten or fifteen minutes, and
this period is shortened a great deal when you
use the combined anesthesia. Also it shortens the
interval following operation, for the patient comes
out from under the influence of this form of an-
esthesia almost immediately. There is some differ-,
ence in the amount of post-operative ’ nausea. Un-
der combined anesthesia there is not nearly the per-
centage of cases of post-operative nausea as there is
even with ether given by the open method, and it is
particularly nice in extended cases where you can-
not use local anesthesia throughout, but must have
a genera] anesthetic for a few moments during the
heaviest part of the operation. But the most im-
portant thing of all, to me at least, is the fact that
it is necessary to have an expert to administer the
combined anesthesia. You cannot depend on some
one who knows nothing about it, because in inex-
perienced hands it is the most dangerous anesthetic
that we have an}^thing to do with, and should, I be-
lieve, never be used without the preliminary injection
of morphin and atropin. There is one other thing
we have to take into consideration in our private
work, and that is the cost of the anesthetic. One
anesthetizer kept a very close record of the length
of time and the amount used, and found that the
actual cost for the gas would amount to about $7 an
hour. Therefore if you are giving this anesthetic
right along you will find that it is quite an item in
your expense, and this constitutes one of the prin-
cipal objections to its use in private practice. In us-
ing either ether or the nitrous oxid and oxygen, I
have alwaj'S firmly believed that a preliminary injec-
tion of morphin and atropin is a very great aid to the
patient in going under the anesthesia, and whatever
is an aid to him in lesening the nerv^ous condition is
also an aid to you in your after-care of these pa-
tients, because the greatest factor in after-care is
the mental attitude of your patient when he goes
under the anesthetic, the way he is managed through
the period of anesthesia, and the careful handling of
tissues during the operation.
Dr. P. B. McLaughlin, Sioux City — This new era
of local anesthesia which has developed in the last
few years is to me one of the most wonderful things
that could possibly happen to us, for this one rea-
son: The delicate manipulation of tissue that a sur-
geon must necessarily employ if he is going to suc-
cessfully operate under local anesthesia cannot help
but make a better surgeon of him. A man using
local anesthesia cannot tear or rip or pull or abuse
tissue, and in the reparative process that follows his
operation this surely is a great factor. The work
done by one whom we might call the psychological
anesthetist, preparatory to the patient’s entrance to
the operating room, is another and most important
element in favor of this method. Then again, with
local anesthesia the general comfort of the patient
on the operating table must be considered. In the
ordinary hospital it is nothing unusual to see a pa-
tient brought into the operating room on an iron
slab with nothing but an oil cloth and sheet on top
of it. We are not accustomed to going to sleep on
an iron slab, and with the complete relaxation in-
duced by ether anesthesia and lying there for an
hour, it is no wonder we have terrific backaches and
pains all over the body when we are returned to our
bed and wake up from the anesthetic. Another thing
that I have been taught since doing local anesthesia
is the minimizing ' of rnanipulation and pull on the
mesentery. Where you are doing an ordinary ap-
pendectomy under local anesthesia you can simply
lift the appendix and pull it out of the abdomen, and
in ten seconds that patient will be vomiting. If you
keep traction off the mesentery he will go through
local anesthesia without vomiting.
Dr. John E. Brinkman, Waterloo — I want to em-
phasize one poii)t made by the essayist, and that is
the time of the preliminary administration of com-
bined anesthesia. He said one hour, which I think
is a splendid idea. To give the hypodermic fifteen
or twenty minutes before general anesthesia is be-
gun, is not long enough. The soothing effect that
you get from morphin, the drying of the mucous
membranes from atrophin, do not have time to take
place if the hypodermic is given shortly before.
Rather than to give it but fifteen or twenty minutes
before, I would prefer not to give it at all, because
then you arc getting the combined effect at a time
when you least desire it. In other words, about the
time you get the patient under the anesthetic, along
comes 3'our morphin and you are getting more an-
esthesia than you need. Therefore the point is very
well taken to give it a long enough rime before so
that you get the full physiological effect of your
hypodermic before administering the anesthetic. In
Dr. Voldeng’s splendid talk yesterday on luminal, I
think he said that this agent had no appreciable ef-
fect on pulse, respiration, or temperature. We some-
times find people who have an idiosyncrasy for
opiates, and since hearing Dr. Voldeng’s paper it has
occurred to me that if luminal is hypnotic in a way.
VoL. XII, No. 61
Journal of Iowa State ^Medical Society
231
as indicatetl in tlie reported cases in which patients
would sleep for hours following its administration,
would it not be worth trying in those cases? I would
like to hear Dr. Voldeng discuss this point, not that
luminal may have any preference over morphin, but
we do know that there are certain cases in which,
unless you give a very large dose of morphin, you
stimulate instead of soothe.
Dr. Ryan — In connection with the use of combined
anesthesia. Dr. Armentrout spoke of the necessity of
having trained anesthetists. I want to further em-
phasize this point, not alone for nitrous oxid and
O-xygen anesthesia, but I believe we arrived some
time ago at the stage where the anesthetic and its
importance should be recognized and realized. That
is to say, everywhere and at all times possible a per-
son should be a trained anesthetist before being al-
lowed to administer any anesthetic, whether it be
ether, chloroform or nitrous oxid. The daj' of
“pouring ether” is past. I remember in my school
days seeing men pour ether, meanwhile looking
around and recognizing their friends in the amphi-
theater and probably carrying on a conversation as
to what they were going to do that evening. I hope
that day is past in anesthesia. We should realize that
the anesthetic is a most important factor in surgical
procedure, and while ether does not require the in-
timate knowledge and experience in its administra-
tion, I do not think any of us realize just how much
after-effect can be charged up to ether. The point
that strikes me most forcibly is that we have entered
on an era in which the anesthetist should be a
specialist just the same as is the eye, ear, nose and
throat man, and I hope that fact will be realized as
rapidly as possible by the profession in general.
It is true that the combined anesthesia is more ex-
pensive, but in my experience, after explaining to the
patient the difference in the expense of ether and
nitrous oxid anesthesia, in by far the majority of
cases the reply has been, “Well, I want the best, I
want to get through as easily as possible and with
the least amount of trouble possible.” And I have
found that they are willing to pay the expense them-
selves when the matter is explained to them, al-
though I will admit that it is a factor. Dr. AIc-
Laughlin also spoke of a very important point, and
that is a comfortable pad for the table. .1 think those
of us who have been on an operating table can ap-
preciate what he has said, and I have been there, I
have been the recipient of all kinds of anesthesia and
therefore speak from experience. If you want to try
it, lie on a hard table for thirty minutes, not moving
while awake, and see what the effect is. In connec-
tion with this, another thing that is sometimes done,
and which I think should be relegated to the past,
and that is strapping the patient’s hands or arms
down on a board before the anesthetic is started.
Those who have been on an operating table can ap-
preciate this; those of 3-011 who have not can hardly
realize just what these little things mean. I thought
I knew something about it before mi- experience,
but found that I could learn a lot, and I will tell
you that I would not permit anybody to tie my arms
or hands down before the anesthetic was started.
And I will not permit it in m\- work, and it is not
necessary if 3-011 have an anesthetist that knows and
will pa3' attention to his business.
NATIONAL BOARD OF MEDICAL
EXAMINERS
The dates for the next two examinations of the
National Board of Medical Examiners are as follows:
Part I and II, June 19, 20, 21, 22 and 23, 1922. Part
I and II, September 25, 26, 27, 28 and 29, 1922.
Applications for the June examination should be
in the secretar3-’s office not later than Ma>- 15, and
for the September examination not later than June
1. Application blanks and circulars of information
may be had b\- writing to the secretar3'. Dr. J. S.
Rodman, 1310 ^ledical Arts Building, Philadelphia,
PennS3'lvania.
Kindl3' publish this statement in your Journal as
soon as possible.
Very truly 3'ours,
J. S.' RODMAN, Sec’y.
AMERICAN SOCIETY FOR THE CONTROL
OF CANCER
The following officers of the society were elected
for the 3'ear 1922: Dr. Charles A. Powers, president;
Dr. George E. Armstrong, Dr. Clement Cleveland,
Dr. Livingston Farrand, Dr. Rudolph Matas, vice-
presidents; Thomas M. Debevoise, secretar3-; Dr.
Calvert Brewster, treasurer, U. S. Mortgage & Trust
Co.; Sir .\rthur Xewsholme, honorar3' vice-president.
All these officers held office during the previous
3'ear, with the exception of ^Ir. Calvert Brewer, who
replaced Mr. Howard Bayne as treasurer, Mr. Ba3'ne
having resigned because of pressure of other duties.
Dr. Charles N. Dowd, Dr. John C. A. Gerster, Mr.
Calvert Brewer and Mrs. Samuel Adams Clark, all of
New York City, were added to the board of di-
rectors.
Des iloines Doctors: We neighbors are more
dependent on you than perhaps on an3' other class
of citizens in our town — and what’s more we’re proud
of 30U. Among 3'our number are surgeons that
would be internationalh- famous in wider fields and
ph3'sicians whom I would trust in direst need as
fulh" as those whose names are household words, be-
cause of a metropolitan setting — and their fees. But
don’t 3'ou think that $5 for a house call is a bit steep
in these da3's of deflation? Fortunateh' it doesn’t
hurt me, because I so seldom have need for 3-our
services. But it looks to me as though you were
soaking the sick folks of our own town too hard.
If 3'ou aren’t careful the spirit of Charlie Miller,
hovering over the state house, will inspire some leg-
islator to go and do likewise — with more serious re-
sults for 3'ou than Iowa histor3' now records. — The
Neighbor, Des Moines News.
232
JOL'RXAL OF Iowa State Medical Society
[June, 1922
®f)c Journal of tbc
Sotna ^tate iWcJjical ^ocietp
D. S. Fairchild, Editor Clinton, Iowa
Publication Committee
D. S. Fairchild Clinton, Iowa
\V. L. Bierring Des Moines, Iowa
C. P. Howard Iowa City, Iowa
Trustees
J. \V. COKENOWER
T. E. Powers
\V. B. Small
SUBSCRIPTION $2.75 PER YEAR
Books for review and society notes, to Dr. D. S.
Fairchild, Clinton. All applications and contracts
for advertising to Dr. T. B. Throckmorton, Des
Moines.
Office of Publication, Des Moines, Iowa
Vol. XII June 15, 1922 No. 6
THE SEVENTY-FIRST ANNUAL SESSION OF
THE IOWA STATE MEDICAL SOCIETY
The Seventy-first Annual Session of the Iowa
.State Medical Society convened at Des Moines,
May 10, 11 and 12, with an attendance of nearly
600 members registered. The exact number be-
ing 575.
\'ery few papers were missing and the discus-
sions unusually free and by careful watching the
schedule was on time. Several notable papers
were presented. The address by Dr. Christian of
Boston, and Dr. Davis of Philadelphia excited
much interest.
The address delivered by Dr. A. IM. Pond, the
retiring president was full of practical good
sense, and pertinent to the changes in the medical
practice of today. Dr. Pond referred particularly
to the unnecessary fears that appear to gain pos-
session of the minds of some of unfriendly legis-
lation, particularly to forms of state medicine,
compulsory health insurance, maternity bills and
other bogies. Dr. Pond does not appear to fear
in Iowa, adverse legislation if the medical pro-
fession performs its full duh- to the public as a
profession. In this we fully concur, and never
seriously entertained the thought that the people
would refuse the medical profession all the credit
it was entitled too. We however, have reason to
believe that the public will hold the medical pro-
fession to a strict accountability for unskilled or
negligent practice.
The House of Delegates is always watched
with interest as to its conduct of the essential
business of the Society; its selection of officers
and committees, and the expenditure of the So-
ciety’s money. The new plan of co-ordinating
the state activities in which the medical profes-
sion should have an important part, was subject
to discussion and inquiry. The committee ap-
pointed under a resolution suggested by Presi-
dent Don IMacrae last year, after a year of study,
made an elaborate report which will be found in
the proceedings of the State Society and an ap-
propriation of $7,500 was made. This may be
an experiment, but probably in the right direction.
Time will determine the results and the modifica-
tions necessary, but it is clear that something
should be done in the way of field activities to
co-ordinate matters of interests to the public and
the profession.
For the past three or four years, we have been
trying to believe that we are the most unfortun-
ate of men. We have made many attacks on the
wind mills with the experience of Sandro Panza.
The Illinois IMedical Journal has devoted many
pages to the dangers of poverty and approaching
slavery of the medical profession from compul-
sory health insurance. Michigan has been in the
greatest danger from the ruinous influence of its
great university on the medical profession, and
the profession in Minnesota is in equal danger
from the IMayo Foundation, although Minnesota
IMedicine and Northwest Lancet have not shown
equal anxiety. If there is, or has been any real
danger, the situation would indeed be serious.
During the war, certain experiences came up that
would appear to show that the medical profes-
sion was not meeting public expectation and cer-
tain commercial manifestations were appearing
that tended to lessen the confidence of the public
in the claims made by the profession, particularly
in relation to the conservation of public health,
which would appear at least, to lessen the busi-
ness of doctors. The growing faith in the ad-
vantages of workmen’s compensation in business
circles gave countenance to the idea of medical
practice being a public service. The spread of
this idea in European countries, led to the dis-
cussion of this plan of medical practice in the
United States.
The violent an unreasoning antagonism to this
plan, threatened at one time to lead to some ex-
periments in this direction in the United States.
So violent was the opposition that conservative
men who believed that important suggestions for
the im]rro\ement in the methods of practice
should be seriously considered were subjected to
Des Moines, Iowa
Clarinda, Iowa
Waterloo, Iowa
VoL. XII, Xo. 61
Journal of Iowa State ^Medical Society
233
most bitter attacks. That some of the most prom-
inent and successful members of the medical pro-
fession should advocate a plan that would de-
stroy the influence of the profession seems too
absurd to merit serious consideration. It is grat-
ifying to say that this feeling never prevailed in
Iowa. The State University has never been ac-
cused of tiA'ing to enslave or of pauperizing the
profession, or to destroy its influence in the in-
terest of a university group.
The profession in Iowa has been willing to
discuss the question of state medicine (whatever
that may mean) without excitement or prejudice,
realizing that certain interests were considering
medical service under different conditions from
what we had been accustomed to in the past.
In business, contract service had been accepted as
a principle and it was easy to extend this princi-
ple to medical and surgical service. The United
States Army had employed contract surgeons,
transportation companies and industrial corpora-
tions employed contract medical service, lodges
of various kinds had done this same thing and it
was only a step to extend this kind of service to
the general public. The bitter attacks of the past
of the profession, on what the public regarded as
a welfare service, created a suspicion of selfish-
ness on the part of the profession, and that the
claims on the part of the profession to serve the
public were without foundation.
It was also held that the large sums of money
furnished by the public in the education of doc-
tors gave the public, special claims on the medical
profession.
Conservative men in the profession believed
that the true relations of the medical profession
to the public were worthy of serious discussion
even at the risk of being misunderstood. The
result of this discussion seem to show that the
method of practice must vary in different sec-
tions of the country and under different condi-
tions. It would be quite absurd to suppose that
agriculture coul,d be carried on in all sections of
the countr}' with the same detail. Agriculture in
the Mississippi Valley, in the hill farms of X'ew
England, X'ew York, Pennsylvania and in the
South is not quite the same. The same principles
may be involved but the method must necessarily
differ. So must the details of the practice of
medicine.
It is difficult to see how the practice of medi-
cine can in its general plan, in different sections
of the countr}', be arranged by legislation ; it must
come by a process of evolution, as the result of
experience. There is absolutely no reason for
any form of state medicine in Iowa or in states
like ours and we have never seriously considered
it. W'e have discussed compulsory health insur-
ance and as the result of this discussion, we have
gradually adjusted ourselves to changed condi-
tions. Each county arranged its relation to the
public. Some counties have been more forward
than others. Some have adopted methods which
have been modified or are in the process of mod-
ification. Other states having large industrial
cities, may find it necessary to adopt methods dif-
ferent from others. In other states where coun-
try life and agriculture is different from ours,
other methods must be worked out and by the
profession itself, not by legislation. It is diffi-
cult for us in Iowa to understand the violent
agitation that is going on in some of our neigh-
boring states and the horrible fears expressed of
pauperization and slavery which is threatening
the medical profession.
We firmly believe that at no time in the his-
tory of medicine, has there been a higher public
appreciation of the medical profession than at
present. The large gifts made by rich men in
support of medical education and the appropria-
tions by states in support of medical universities
should be evidence of this. It is true that legis-
latures have given recognition to methods of prac-
tice of medicine quite different from ours, but
this is not evidence of an unfirmly attitude, but
is in accordance with our democratic principles of
government. E\ery class is entitled to equal op-
portunity, and we gain nothing by denying this
principle. It remains for us to keep our house
in order and render to our patients and to the
public what lies in us, keeping in mind always
that ever}- man and every profession must in the
end stand on its own feet.
The important thing to consider is the provid-
ing as near as may be, the best facilities for the
treatment of disease. This is not accomplished by
waring on other systems, or methods of practice,
but by developing our system or methods. In our
opinion, the fundamental fact is in developing
what the public is manifesting a remarkable in-
terest in, and that is, the building and supporting
some form of community hospital in almost ev-
ery village of importance. This work is going on
with some temporary failures, it is true, but it is
a beginning; we are learning by experience and
are readjusting our plans to suit local conditions.
Xot a few doctors find it more agreeable to work
alone, others enjoy the work better in coopera-
tion. The opportunity is open to all. It is clear
enough that no standardized plan of practice can
be adopted until we can all see the world, and all
there is in it from the same point of view. There
234
Journal of Iowa State Medical Society
is of course an economic business side to the
practice of medicine that will appeal to reasonable
men, even if they see things from a somewhat
different angle, that will bring doctors together
as it does business men in general.
RAY LYMAN WILBUR, M.D., PRESIDENT-
ELECT AMERICAN MEDICAL ASSO-
CIATION
Ray Lyman ^\ ilbur, born Boonesboro, Iowa,
April, 1875 ; son of Dwight Locke and Edna
Maria (Lyman) Wilbur, A.B., Leland Stanford
Jr., LMiversity, 1896. A.iM., 1897 ; M.D., Cooper
Medical College, San Francisco, 1899; student,
Frankfurt-on-the-^lain, and London, 1903-190-1,
Imiversity of ^Munich, 1909-1910; (LL.D., L'ni-
versity of California, 1919, University of Ari-
zona, 1919) ; married ^Marguerite May Blake of
.^an Francisco, December 5, 1898. Instructor
physiolog}', Stanford University, 1896-1897 ; lec-
turer and demonstrator physiolog}', Cooj>er ^led-
ical College, 1899-1900; assistant professor phy-
siolog}', 1900-1903, professor' medicine, 1909-
1916, Stanford LMiversity ; dean of Medical
School, Stanford, 1911-1916; president Stanford
University since January, 1916. Chief of con-
servation division United States Food Adminis-
tration, Washington, D. C., 1917 ; member Cali-
fornia State Council Defense, 1917 ; regional edu-
cational director S. A. T. C., District Xo. 11,
1918. President, California State Conference,
Social Agencies, April, 1919. Fellow A. A. A. S. ;
member American Academy ^Medicine (Presi-
dent, 1912-13), A. M. A., California Academy
Medicine (President 1917-1918), Phi Beta
Kappa. Clubs: University, Commonwealth, Bo-
hemian, Pacific Lhiion (San Francisco).
OFFICERS OF THE IOWA STATE MEDICAL
SOCIETY ELECTED AT THE RECENT
ANNUAL MEETING
President — Dr. C. J. Saunders, Fort Dodge.
President-elect — Dr. O. J. Fay, Des IMoines.
First \’ice-president — Dr. George Kessel,
Cresco.
Second \’ice-president — Dr. O. F. Parish,
Grinnell.
Secretary — Dr. T. B. Throckmorton, Des
^loines.
Ti'easurer — Dr. Thos. F. Duhigg, Des Moines.
Trustee — Dr. J. W. Cokenower.
Delegates to A. IM. A. — Dr. Donald Alacrae,
Jr. and Dr. W. L. Allen, Davenix»rt.
Alternates — Dr. D. X. Loose, Maquoketa, and
Dr. B. L. Eiker, Leon.
[June, 1922
IOWA STATE UNIVERSITY NEWS NOTES
Dr. Don Griswold
The Eleventh ^Medical Clinic of the College of
Medicine of the State University of Iowa, held April
11-12, 1922, at Iowa City, was well attended, as shown
by the attendance of over 230 physicians of the
state.
. Dr. A. J. Carlson, head of the physiology depart-
ment of the University of Chicago, gave the main
address of the clinic on endocrinology, Wednesday
morning. Clinics were held by the various doctors
in the different departments. Clinics were held by
Dr. L. W. Dean in eye, ear, nose and throat, and oto-
laryngology; by Dr. H. L. Beye in general surger3';
b>' Dr. F. Boiler in ophthalmology; by Dr. Clarence
Van Epps in neurology-; by Dr. Arthur Steindler in
orthopedics; b\- Dr. J. B. Kessler in dermatologj'; bj'
A. H. Byfield in pediatrics; bj- Dr. F. H. Falls in
gynecology; by Dr. Fenton on fractures of the jaw;
b^' Dr. C. P. Howard in internal medicine; bj" Dr
X. G. Alcock in genito-urinar\- surger\-.
Wednesday afternoon, all visitors inspected the
new psj'chopathic hospital across the river, in charge
of Dr. S. T. Orton.
The department of obstetrics of the University
Hospital is undergoing a thorough reorganization.
To keep pace with the growth of the clinic, addi-
tional quarters have been provided and now all t\pes
of obstetrical service can be carried out under the
best of circumstances.
Entireh' separate housing is furnished for the
legitimateh' pregnant waiting cases. Separate de-
liver>' rooms are provided for venereally infected
cases. A special post-partum ward, and a few
private rooms are provided for those complicated
cases that need special care after deliver}'.
Three nurseries are provided for the babies which
gives opportunit}' for proper segregation of cases
showing any evidence of infection.
The deliver}' rooms are designed and equipped for
taking care of every obstetrical emergency. Cesar-
ean sections ruptured ectopic pregnancy and other
major abdominal operative cases are handled in the
main surgical amphitheater.
A well organized adoption service for babies whose
parents are not venereally infected is an important
element in the service.
Dr. Chase is making week-end trips over the state
during April and ilay in the interests of the recruit-
ment of pupil nurses for the University Hospital
School of Nurses. Among other methods which he
is employing is an endeavor to bring into an af-
filiation as many of the accredited colleges of Iowa
as possible with reference to a combined course for
the degree of “Bachelor of Science and Certificate
of Graduate Nurse.” He reports that he is meeting
with much encouragement along this line.
The Doctor has in mind many other services in
VoL. XII, No. 61
Journal of Iowa State Medical Society
235
behalf of the College of Medicine and its hospitals
and adjunct schools, which will occupy his full time.
The new Venereal Disease Hospital which has
been in operation now" but a very short time is filled
to its capacity. This has unfortunately necessitated
the turning away of a number of patients.
To be certain of the entrance of a patient into
this L’enereal Disease Hospital, arrangements should
be made with the hospital before the patient arrives.
Dr. L. W. Dean, dean of the College of ^Medicine,
has presented several specimens of rare birds to the
museum of the University. The director of the
vertebrate museum says that the specimens are in
e.xcellent shape and will add considerable interest to
the local collection.
Dr. Dean has financed two expeditions for the
vertebrate museum and has aided materially in ac-
quiring a fine collection of birds and fish.
The University of Iowa is doing some intensive
campaigning to recruit students in the training
school for nurses, and they are sending two gradu-
ate nurses out through the state to present to high
school and college students the possibilities of nurs-
ing as a profession for young women. There has
been too little understanding on the part of the pub-
lic heretofore of our schools of nursing and the va-
rious possibilities of the nurse. Miss Stella Venard,
the supervisor of the operating room, and Miss
Lillian Anderson, the head nurse of the medical de-
partment, who have been chosen to present this sub-
ject of the training of young women in our schools
of nursing of today, are well qualified to speak of the
matter at first hand. They are to present this as vo-
cational work and to urge young women who are
giving consideration to this subject to look into the
matter thoroughly, stressing especially those schools
which are giving prime consideration to the educa-
tional side in order that the advanced standard of
nursing may be maintained.
Dr. C. P. Howard presented a paper before the
Association of American Physicians, which met at
Washington, D. C. the first part of Alay, 1922.
MEDICAL NEWS NOTES
The Waterloo Medical Association endorsed the
seventy-five minutes for lunch campaign now" being
carried on in the East District Schools. The medi-
cal men, in a discussion of the case, were of the
opinion that the child kept in school from early
morning until late afternoon was not getting suffi-
cient outdoor exercise.
An action in the district court was brought ^Ion-
day afternoon, April 24, by Dr. O. C. Morrison, nam-
ing the Carroll Clinic, incorporated, and Drs. F. \'.
Hibbs, C. C. Bowie and H. R. Pascoe as defendants.
A three days’ clinic which will be an outstanding
event in state medical circles will be held in Oc-
tober by the Polk County Jtledical .\ssociation.
In charge of the clinical program are Dr. A. P
Stoner, president of the association; Dr. lames T.
Priestley, president of the }ilercy Hospital staff; Dr.
A. C. Page, president of the ^lethodist Hospital
staff; Dr. W. S. Conkling, president of the Lutheran
Hospital staff; Dr. W. L. Bierring, president of the
Samaritan Hospital staff, and Dr. E. G. Linn, presi-
dent of the Congregational Hospital staff.
The arrangements committee includes Dr. F. K
Holbrook, Dr. AI. L. Turner and Dr. Ralph H.
Parker.
Publicity is in charge of Dr. Thomas F. Duhigg,
Dr. W. E. Sanders and Dr. D. J. Glomset.
Notice to Physicians
Sealed bids will be received by the board of su-
pervisors of Boone County, low’a, until 12 o’clock
noon on Alonday, April 17, 1922, for services a^
county physician for the ensuing year.
Bids will be opened at 1:00 o’clock p. m. and con-
tracts awarded.
Board reserves the right to reject any or all bids.
ARCHIE PATTERSON,
Boone County Auditor.
April 22 marks the passing of the last of the old
independent medical weeklies — the Aledical Record.
The final issue as a separate publication appeared
on that date and announcement was made that the
Aledical Record had been sold to, and combined
with, the New York Aledical Journal, which appears
semi-monthly.
Throughout the fifty-si.x years of its service to the
profession, the Aledical Record has had the same
publishers and but two editors. Dr. George F
Shrady guided its course for the first thirty-eight
years and was succeeded by his assistant. Dr.
Thomas L. Stedman, w'ho bas long been dean of
American medical editors, and widely esteemed. The
famous old firm of William Wood & Company w'ill
now devote its energies entirely to the publication
of medical books in which service it has been en-
gaged for 118 years.
It is interesting to recall that many of the most
important discoveries and developments in the prog-
ress of medicine were first announced to the Ameri-
can profession by the Aledical Record. These in-
clude Lister’s method of antisepsis; Koch’s discov-
ery of the tubercle bacillus and that of tuberculin;
the employment of cocaine in e}"e surgery; the roent-
gen rays; the discovery of the antitoxin of tetanus
and that of diphtheria; Aladame Curie’s discovery of
radium and many others.
236
Journal of Iowa State Medical Society
[June, 1922
SOCIETY PROCEEDINGS
Cerro Gordo County Medical Society
Meeting of the Cerro Gordo County Medical So-
ciety was held at Clear Lake, Iowa, l^Iay 23. Dinner
was served in the Watkins Cafe at 6:45 P. !M., which
was enjoyed by the twenty-four members present.
After the dinner the business meeting was called, fol-
lowed by paper on ^Medical Ethics, by Dr. N. W.
Phillips. Discussion by Drs. F. G. Murphj-, J. C.
Wright and H. M. Hoag. Presentation of case his-
tories of some interesting nervous diseases, by Dr.
L. R. Woodward. Presentation of a case of Hemi-
plegia, by Dr. E. L. Wurtzer.
Wilbur L. Diven, Sec’y-
Johnson County Medical Society
At the meeting of the Johnson County Medical
Society held April 18 at Iowa City, An Outline for
the County Health Center under the auspices of the
School of Public Health Nursing of the University,
was presented and a committee from the Society was
appointed to assist in the carrying out of the pro-
ject, Drs. Scarborough, Albright and Bennett con-
stituting the committee. Dr. G. C. Albright read a
paper on Reflex Nasal Neuroses and Dr. A. Steindler
presented a paper on Variations in the Spinal
Column. L. G. L.
Plymouth County Medical Society
Plymouth County IMedical Society met on Tues-
day evening at ^lerrill, where they were guests of
Dr. G. F. Vernon and Dr. A. Naffziger of Merrill,
and Dr. F. W. Fletcher of Hinton. Dr. R. F. Bel-
laire of Sioux City, gave an interesting demonstra-
tion of x-ray pictures and Dr. Vernon read a paper
on influenza and its treatment.
Marion County Medical Society
The Clarion County ^Medical Society met in reg-
ular April session the afternoon of April 20, in the
rooms of the Knox^■ilIe Chamber of Commerce.
Dr. Wm. E. Sanders of Des Moines presented the
subject of The Alanagement of Cardiac Disease in a
most interesting and instructive manner.
Dr. F. R. Holbrook also of Des ^Moines, gave a
most able discourse on Fractures with particular em-
phasis on the frequent use of the x-ray during pro-
cess of treatment.
Eighteen members and visitors were in attendance
prominent among whom was Dr. Channing Smith of
Granger, councilor of the Seventh District.
The ne.xt meeting will be held in Knoxville in
June.
C. S. Cornell, Sec’y.
Tama County Medical Society
The Tama County Medical Society met at Glad-
brook, April 21. Twelve members and their wives
were in attendance. A dinner was enjoyed at the
Methodist Church followed by readings given by
Miss Agnes Law of Traer, formerlj- of the Cummack
School of Oratory, Evanston, Illinois.
At the business session, a county fee bill was
adopted, and the following officers elected for the
year: A. A. Pace, Toledo, president; Knight E. Fee,
Toledo, secretar3--treasurer, and J. A. Pinkerton,
Traer, delegate. C. W. Maplethorpe, Toledo, pre-
sented a paper on Intestinal Infections in Children;
on account of the recent epidemic in the county,
this paper was of more than ordinary interest. H.
V. Hasek, read a ver\- interesting paper on Diagnosis
and Treatment of Common Skin Diseases.
A. A. Crabbe, Sec’y.
Wapello County Medical Society
Dr. K. L. Johnson and Dr. J. G. Roberts were
guests of the Wapello Counte- Aledical Societ}' at a
meeting and banquet at the Hotel Ballingall, Ot-
tumwa, Tuesday evening, April 4. Dr. Fairchild, of
Clinton, addressed the meeting, delivering a most
scholarly’ address. A notable thing concerning the
meeting was that of twenty-seven men present
twelve were ex-service men and members of the
American Legion.
Southwestern Iowa Medical Society
The Southwestern Iowa Aledical Society was held
at Creston, April 20.
Officers — President, R. J. Matthews, Clarinda;
vice-president, F. L. Williams, Villisca; secretary, J.
S. Coontz, Garden Grove.
The program was as follows: Glioma of the
Cerebral Hemispheres, a comparative study of two
cases. Dr. Tom B. Throckmorton, Des Moines. The
County Medical Society, Dr. Donald Alacrae, Jr.,
Council Bluffs. The Relationship of the Ph^’sician
to Public Health, T. J. Edmonds, Des iMoines. The
Unification of iMedical Influence, Dr. Erank AI.
Fuller, Keokuk.
Northwestern Iowa Medical Society
The regular spring meeting of the Northwestern
Iowa IMedical Society was held at Sheldon, .'X.pril 26.
Banquet at Hotel iMe\'ers at 7:00 p. m.
^Meeting called to order at Commercial Club rooms
at 8:00 p. m.
Clfficers — President, F. S. Hough, Sibley; vice-
president, F. W. Cram, Sheldon; secretary-treasurer.
Jay AI. Crowlejq Rock Rapids.
Censors — F. J. Mc.Allister, 1922; H. L. Aver\', 1923;
D. G. Lass, 1924; Peter I. Dahl, 1925.
Committees — Local arrangements, F. W. Cram.
Resolutions — D. G. Lass, H. J. Brackney, L. L. Cor-
coran. Publication — F. P. Winkler, G. H. Boetel,
G. C. Vermeer, G. Maris. Consolidation — McAllister
(cbairman), Corcoran (vice-chairman). Cram, Wink-
ler, Roland.
The program was as follows: Pneumothorax,
Traumatic in Origin — Case Report, Dr. D. C. Snyder.
VoL. XII, No. 6]
Journal of Iowa State Medical Society
237
President's Address, Dr. F. S. Hough. Foreign
Bodies in Respiratory and Food Passages, Dr. J. B.
Naftzger, Sioux City. Paper, Dr. Wm. Maris.
VVertheim film sliown at the Lyric Theatre — Clini-
cal examination for pregnancy, abnormalities of
skeleton, normal delivery, breech presentation, face
presentation and delivery, resuscitation of a child,
Walcher pasture, eclampsia, breech presentation with
extraction of child, podalic version from head pre-
sentation and extraction of the foetus by the foot,
extraction of the dead foetus by the foot with
perforation of the after coming head, craniotomy
(perforation of a skull of a dead foetus), forceps de-
livery, Caesarian section, Caesarian section with hy-
dramnios, examination of prolopse of uterus, re-
moval of ovarian cyst by laparatomy.
The Iowa and Illinois Central District Medical
Association
The regular April meeting of the Iowa and Il-
linois Central District Medical Association was held
at the Rock Island Club, Friday evening, April 21,
at 8 o’clock. Dinner was served at the club at 6:30
at which the visiting essayist was present.
The evening’s program consisted of two papers by
Dr. James T. Case of Battle Creek, Alichigan: (a)
New Deep Therapy in the Treatment of Malignancy,
(b) Differential Diagnosis of Right Upper Quad-
rant Lesions, with special reference to X-ray help.
His papers were illustrated with lantern slides.
A. T. Leipold, Sec’y.
Tri-State Medical Association of Iowa, Illinois and
Wisconsin
It is announced that the annual fall meeting of the
Tri-State Medical Association of Iowa, Illinois and
Wisconsin will be held at Peoria, Illinois, October
30-31, and November 1 and 2, 1922.
The following are the officers of the Association:
Honorary president of clinics. Dr. William J. Mayo,
Rochester, Minnesota; honorary president. Dr. James
R. Guthrie, Dubuque; president. Dr. John E.
O’Keefe, Waterloo; president-elect. Dr. Horace M.
Brown, Milwaukee, Wisconsin; vice-president, Wis-
consin, Dr. Jos. S. Evans, Madison; vice-president,
Illinois, Dr. Edwin P. Sloan, Bloomington; vice-
president, Iowa, Dr. Frank M. Fuller, Keokuk; man-
aging director. Dr. Wm. B. Peck, Freeport, Illinois;
secretary-treasurer. Dr. Domer G. Smith, Freeport,
Illinois.
Dr. H. G. Langworthy is a trustee and organizer of
the organization’s foundation fund and one of the
active men of the organization since its inception.
Southern Minnesota Medical Association
Mid-summer meeting of the Southern Minnesota
Medical Association will be held June 19 and 20, 1922,
Rochester, ^linnesota.
Among the speakers from outside the state who
will be guests of the Association and will appear on
the scientific program are: Dr. W. B. Cannon, Bos-
ton, Alassachusetts; Dr. Judson Daland, Philadelphia,
Pennsylvania; Dr. Fred H. Albee, New York City,
New York; Dr. William B. Coley, New York City,
New \ork; Dr. George E. Shambaugh, Chicago, Il-
linois; Dr. Willis Campbell, Memphis, Tennessee;
Dr. Herman L. Kretschmer, Chicago, Illinois; Dr.
Preston H. Hickey, Detroit, Michigan; Dr. Nathaniel
G. Alcock, Iowa City, Iowa; Dr. George V. I. Brown.
Milwaukee, Wisconsin; Dr. M. G. Seelig, St. Louis,
Missouri; Dr. George W. Heuer, Cincinnati, Ohio.
The program for the forenoon sessions of Mon-
day, June 19 and Tuesday, June 20, will consist of
Surgical and Medical Clinics, and Demonstrations in
all departments at the following hospitals: St.
Mary’s Hospital, Colonial Hospital, Worrell Hospi-
tal, Curie Hospital, Olmstead Hospital, Clinic
Building.
The program for the afternoon sessions will con-
sist of scientific papers, and the mid-summer ban-
quet will be held at the gymnasium, high school
building, Monday evening, June 19, 1922, at 6:00 p. m.
In purchasing your railroad ticket be sure to get
your certificate which, when countersigned by the
secretary-general, will entitle you to one-half return
fare.
ilake your hotel reservations early by addressing
Mr. Roy Watson, chairman committee of arrange-
ments, Southern Minnesota Medical Association,
Rochester, Minnesota.
The official program will be published by May
15, 1922.
Program Committee— Dr. H. W. Meyerding, chair-
man, Rochester; Dr. J. C. Staley, St. Paul; Dr. B. P.
Rosenberry, Winona; Dr. Aaron F. Schmitt, ex-
officio, Minneapolis, Minnesota, secretary general,
705-707 P. & S. building.
The Sioux City Welfare Bureau was staffed on
March 15 last, and officers elected for the current
year. Dr. John W. Shuman, president; Dr. W. E.
Cody, vice-president; Dr. Arch F. O’Donoghue, sec-
retary. Heretofore the clinic had been operated by
volunteers from the Woodbury County Society. The
staff meets on the second Wednesday of each month.
The meeting of April 12 was well attended. Papers
were read by Drs. R. N. Waters and J. E. Reeder on
general and local anesthesia respectively.
Arch F. O’Donoghue, M.D., Sec’y.
HOSPITAL NOTES
A new home for Mercy Hospital nurses, Dubuque,
was formally opened March 26. Sister Gregory in
charge of the home and Sister Mary Philomena,
superintendent of nurses.
Finley Hospital of Dubuque is giving a series of
lectures on public health matters which are open to
all those interested. The following is the list of the
lectures and dates: March 9 — What the Public
Should Know About Cancer, Dr. F. P. McNamara.
238
Journal of Iowa State Medical Society
[June, 1922
March 16 — How the Public Health Laboratorj’ Pro-
tects Your Health, Harold A. Grimm. ^larch 23 —
W hat an Adequate Diet Means, ^lary Cunningham.
March 30 — Diphtheria; Detection; Modern Treat-
ment; Prevention; Demonstration of Shick Test,
Dr. F. P. !McXamara. April 6 — The Nurses’ Train-
ing School as a Community Asset, X. Adele North-
rop. April 20 — Are You Getting W'hat You Pay For?
Harold A. Grimm. April 27 — What Hospital Stand-
ardization !Means to the Community, Dr. F. P. Mc-
Namara. F. P. ^McNamara.
The Grinnell Community Hospital Association,
through the terms of the will of the late Sophronia
Georgia Turner, has received a bequest amounting to
between $20,000 and $25,000,. according to an an-
nouncement made by Dr. O. H. Gallagher before a
meeting of the directors and some of the staff.
By the terms of the will, the trustee, W^. C. Ray-
burn, may dispose of the entire estate and convert
the sum realized into a bond or real estate invest-
ment, the income from which goes to a sister of Itliss
Turner, Rosetta Powers, for the rest of her life and
at her death the whole reverts to the hospital asso-
ciation for the maintenance and benefit of the Com-
munity Hospital, or its successor.
The present officers of the Community Hospital
staff are Dr. O. F. Parish, Grinnell, president; Dr.
E. B. Whlliams, Montezuma, vice-president; Dr. P.
E. Somers, secretary. Following is a full list of the
hospital staff, elected by the hospital board to date.
Dr. C. D. Busby, Brooklyn; Dr. Elias Barge, Monte-
zuma; Dr. L. L. Gould, Kellogg; Dr. J. C. Ravitts,
^lontezuma; Dr. E. B. Williams, ^Montezuma; Dr.
Delano Whlcox, Malcolm; Dr. G. B. W’ard, Gilman;
Dr. E. S. Evans, Grinnell; Dr.WV. W. Hansell, Grin-
nell; Dr. L. A. Hopkins, Grinnell; Dr. J. R. Lewis,
Grinnell; Dr. C. H. Lauder, Grinnell; Dr. O. F.
Parish, Grinnell; Dr. P. E. Somers, Grinnell; Dr.
E. E. Talbott, Grinnell.
The hospital at Akron, Iowa, which was recently
dedicated, is a former dwelling remodeled at a cost
of $5000. The equipment is modern throughout with
a complete x-ray outfit, operating and sterilizing
rooms, finished in white enamel and cement floors.
Three doctors and two regular nurses care for the
twenty beds in this institution.
PERSONAL MENTION
Dr. Henry Albert, head of the department of bac-
teriology at the University of Iowa, Iowa City, has
resigned on account of his health and will become
head of the state board of health laboratories of
Nevada, where the Western climate is more suited
to him.
Dr. R. H. Lott of Maquoketa has been appointed
to the management of an eighty bed hospital at
Carroll.
Dr. F. T. Launder of Garwin, homeopathic mem-
ber of the state board of health, was reappointed
Monday, April 24.
In the village of Janesville, Bremer count}', Iowa,
lives a typical country physician. Dr. David S. Brad-
ford. For more than a half century he has practiced
medicine in the village, and in the years now past
literally grown into the life and choicest affection
of its townspeople. The rock-like stability and
worthy attributes of Dr. Bradfords character may be.
traced very easily to William Bradford, governor of
^Massachusetts in the days of the ilayflower, and the
landing of the Pilgrims, to whom the Doctor traces
his ancestry. In 1840 he was born in Schohaire
county. New York, and was graduated from Albany
Medical College in 1866. After only four years of
practice he decided to break into the life of the then
far western part of the United States. Leaving Rock
City Falls, New York, in the spring of 1870 he came
directly to Iowa, and settled in Janesville, where he
has maintained a continuous residence, and unbroken
practice for more than fifty years.
Dr. T. C. Knox has decided to leave ilarcus and
will go to Lawton where he will locate about May 1.
Dr. Knox has resided in Marcus most of his life and
has practiced medicine here for ten years.
Dr. Ben Hamilton left recently for Boston, where
he will enter the medical school of Harvard Univer-
sity for a few weeks’ course of post-graduate train-
ing in the diseases of children including medical and
surgical treatment; also in physical diagnosis. His
work will be -done largely in connection with the
Massachusetts General Hospital.
Superintendent Von Krog has announced the ap-
pointment of Dr. C. iM. Wray, of Iowa Falls, to be
surgeon at the training school to succeed Dr. Key-
ser, of Marshalltown, who has been doing the work
up to this time.
Dr. Guilford H. Sumner, until recently secretary-
executive officer of Iowa State Board of Health, a
resident of Waterloo for manj^ j-ears, has received
many testimonials of his services during the twelve
years he was with the state board. Dr. Sumner still
holds legal residence in Waterloo, though living at
Des Moines. A resolution adopted by the Iowa
State Board of ^Medical Examiners December 28,
1921, said Dr. Sumner had been “an able and ideal
official.” The board included Dr. F. T. Lauder, Dr.
H. S. Eschbach, Dr. G. E. Severs and Dr. C. S. Grant.
These men were also members of the Iowa State
Board of Health.
Dr. J. W. Osborne was elected president of Des
Moines health center at the annual meeting of di-
rectors at the Chamber of Commerce.
Dr. W. W. Beam and Dr. T. R. Campbell, who
have been practicing medicine under the firm name
of Drs. Beam & Campbell, dissolved partnership this
week by mutual consent.
Dr. H. E. Farnsworth was re-appointed health
physician. Storm Lake, by the city council at their
recent meeting.
VoL. XII, No. 6 1
Journal of Iowa State Medical Socit-.iv
239
A degree of fellowship of American College of
Physicians was conferred upon Dr. J. Rowntree, at
the American Congress of Internal Medicine held at
Rochester and Minneapolis last week. A total of
seventy-five degrees were given to men from every
state of the union, eight being conferred upon Iowa
physicians. They are: Dr. G. N. Ryan, Des Aloines;
Tom Throckmorton, Des Moines; S. Gaumer, Fair-
field; \V. Aleis, Sioux City; J. Shuman, Sioux City;
E. M. Williams, Sioux City. ^lany interesting and
scientific papers were read at the convention which
was held at Rochester April 4, 5 and 6; at Alinne-
apolis, April 7 and 8.
Dr. Granville N. Ryan of Des Aloines was selected
by the democrats as their candidate for congress
from the seventh district. He heads the list of can-
didates for state and county offices selected by the
democratic county committee.
Fifty years ago Dr. Winfield Fordyce entered the
active practice of medicine at Glasgow and for one-
half century has continued his labors with untiring
effort in Jefferson county. Although he is in his
seventy-fourth year, he never lets age interfere with
night calls or unpleasant tasks, and his straight and
open forward manner with other members of the
profession, as well as his honesty and simplicity with
his patients has awarded him with one of the largest
practices in the city. Dr. Fordyce was born in Lee
county in 1848, the son of Lewis and Mary Newby
Fordyce. The days of his boyhood and youth were
spent in \’an Buren county, where he was reared to
farm life. However, when he reached twenty-one,
finding that his tastes were not agriculturally in-
clined, he began the study of medicine with Dr. J. M.
^lorris of Birmingham. Later he attended lectures in
the College of Physicians and Surgeons at Keokuk,
Iowa, which place he completed his course in Febru-
ary, 1872. As a testimonial to his long service, the phy-
sicians of the Jefferson County Medical Society ten-
dered him a banquet, given at the Leggett House.
An excellent toast program was arranged and Dr.
S. K. Davis of Libertyville presided as toastmaster.
Dr. A. O. Williams of Ottumwa discussed Boneset
and Other Specialties, while Dr. F. ^I. Tombaugh of
Burlington talked on The Golden Age of Medicine.
When the Doctor Is in, was taken up by Airs. J. S.
Gaumer and As Others See Us, the subject of a short
toast by Dr. C. L. Tennant. The officers of the or-
ganization who planned the dinner are Dr. M. C.
Carpenter, president; Dr. G. K. Dunkel, vice-presi-
dent; and Dr. Charles Ricksher, secretary-treasurer.
Dr. J. S. Gaumer, Dr. Charles Ricksher and Dr. J.
Fred Clarke comprise the committee on arrange-
ments. The invited guests were Dr. and Mrs. W.
Fordyce, Mr. and Mrs. J. M. Burnett, Burlington, Dr.
and Airs. J. A. Roth, Rock Rapids, Dr. and Airs.
Chester Fordyce, Rev. and Airs. C. L. Tennant, Dr.
and Airs. A. O. Williams, Ottumwa, Dr. F. AI. Tom-
baugh, Burlington, Dr. and Airs. S. A. Spillman, Ot-
tumwa, Dr. J. F. Herrick, Ottumwa, Dr. F. C.
Alehler, New London, Dr. T. G. AIcClure, Douds,
Dr. H. E. Woods, Birmingham, Dr. J. Norris, Birm-
ingham, Aliss Ellen .Anderson, Dr. C. S. Bishop, Dr.
and Airs. F. S. Bonnell, Dr. and Airs. AI. C. Carpen-
ter, Dr. and Airs. J. F. Clarke, Dr. and Airs. W. H.
Connor, Dr. and Airs. I. N. Crow, Dr. and Airs. G. K.
Dunkel, Dr. and Airs. S. K. Davis, Dr. and Airs. W.
E. Dodds, Dr. and Airs. J. S. Gaumer, Dr. and Airs.
E. G. Grove, Dr. and Airs. A. S. Hague, Dr. and Airs.
L. D. James, Dr. and Airs. I). H. King, Dr. and Airs.
Chas. Ricksher, Dr. P. J. Sherlock, Dr. and Airs. R
B. Stephenson, Dr. and Airs. J. K. Stepp, Dr. and
Airs. C. C. Tallman.
Dr. Wm. R. Fazio succeeds Dr. J. D. Lowery as
city health physician of F'ort Dodge.
DR. EUGENE A. CROUSE
Dr. Eugene A. Crouse celebrated the fiftieth an-
niversary of distinguished practice at Grundy Center
Alarch 15 under the most agreeable circumstances.
The Grundy County Aledical Society with a deep
appreciation of Dr. Crouse's character and profes-
DR. EUGENE A. CROUSE
sional merits and with that neighborly feeling which
should distinguish every medical practitioner who
have so many things in common joined in an event
which Dr. Crouse will remember with the deepest
gratitude to the end of his days. The life of a
doctor is so full of experiences, many of them of a
trying character, that expressions of appreciation
and affection are the most grateful that can come to
him. While greatness and riches are always wel-
come, yet there is something more; that is difficult
to measure by ordinary standards, that which lies in
the hearts of men.
Not only did his county society join in expressions
of affection, but many of his profession, present and
240
Journal of Iowa State Medical Society
[June, 1922
absent, his lay friends and all whose lot in life
whether under his ministrations or of others who
have felt the need of medical guidance, are filled
with appreciation of what an honest and upright
doctor means in the community and to his profes-
sional associates wherever found.
Dr. Crouse graduated from the Medical Depart-
ment of the University of Pennsylvania March 11,
1870 and located in Grundy Center soon after. Those
were pioneer days, and no one appreciated this fact
more than the country doctor whose cases were
often emergency cases with no time for deliberate
preparation; at night in storm, and roads difficult
to appreciate today. The anxiety of the patient took
no account of the personal danger the doctor was
exposed to. All this was forgotten by Dr. Crouse
when he was surrounded by his many friends who
told him in generous terms their feelings and how
much they appreciated his sacrifices.
Among the members of the profession outside
Grundy county were Dr. Howard of Iowa City, Dr.
Bierring, Des Moines, Dr. McManus and Dr. Small
of Waterloo. Many letters of congratulation were
read.
There is a growing custom in friendly communities
to honor men who have been engaged in active prac-
tice for a period of fifty years. This is more notable
in county districts where warmer friendship exists
than in cities where a more bitter competition pre-
vails.
Dr. Crouse still remains in active practice.
OBITUARY
J. B. H. Feenstra was born at Groeningen, Hol-
land, May 12, 1843, died at Pasadena, California,
April 1, 1921. Coming to the United States soon
after the Civil War he settled at Pella, Iowa, later
going to Ackley, and still later to Arcadia in the
same state. He lived at the latter place thirty-three
years, engaged in practice and conducting a drug
store.
Dr. Leonard DeVore, sixty-eight years old, widely
known physician in Nebraska and Iowa, died at the
home of his son, Alonzo De Vore, 1012J4 Douglas
street, recently after an illness of three weeks. Death
was due to neuritis.
For twenty-five years Dr. De Vore practiced med-
icine at Ponca, Nebraska, moving from there to
South Sioux City, Nebraska, where he remained for
fifteen years. He came to Sioux City to live with his
son January 10.
Dr. De Vore was born on a farm in Noble county,
Ohio, February 22, 1854. He was the son of Mr.
and Mrs. Isaac De Vore. When twelve years old his
parents died leaving him an orphan. For a time the
physician resided with his mother’s parents. Not
contented with his lot, he worked his way West,
settling near Des Moines, Iowa.
Selecting the medical profession as his life’s work.
Dr. De Vore attended Drake University at Des
Moines, working as a barber at the same time. He
was graduated and later attended the college Ames,
Iowa. For a time he practiced medicine at Colfax,
Iowa, and later moved to Ponca. From there he
went to Laurel, Nebraska, where he remained two
years and then moved to South Sioux City.
While in Ponca, Dr. De Vore wrote a book en-
titled “Boy in the Wild West,” which dealt with his
life as an orphan. He described his wanderings in
a vivid fashion since he left his mother’s parents in
Ohio.
Dr. James A. ^IcCroskey, a Civil War veteran and
a resident of Davenport, for the last two years, died
at St. Luke’s Hospital following an illness of two
months’ duration.
He was born in Franklin county, Ohio, July 9,
1839, and was graduated from the New York College
of Medicine. During the Civil War he served fo;
three years under General Dodge in Co. K, Second
Missouri Volunteer Cavalry, and after his discharge
at St. Louis married Miss Mary .Arnold at Macon
City, Missouri.
For twenty years he practiced medicine in Mon-
roe, Iowa, coming to Davenport two years ago to
live at the home of his granddaughter, Mrs. Walter
Heald, 921 East Fourteenth street.
After a lingering illness covering a period of more
than two years Dr. J. W. David passed away Satur-
day morning, .April 22. J. W. David was born at
Olney, Illinois, February, 1841 and when a small boy
moved with his parents to Belmont, Wisconsin.
Later he attended the schools and the academy at
Plattsville, Wisconsin, until the year 1862, when he
enlisted as a soldier in the Civil War. At the close
of the war, after completing his education at Rush
Medical College in Chicago, he returned to High-
land, Wisconsin and purchased a drug store and be-
gan the practice of medicine. He was married in
1866. In 1874 Dr. and Mrs. David moved to Mus-
coda, Wisconsin, where they remained eight years.
They then moved to Forest City remaining there
four years. The family came to Alden in 1886 where
the Doctor continued practice.
Airs. Effie Alice, wife of Dr. Frank T. Hartman,
died suddenly at 7:15 p. m. April 25 at their residence
Mulberry and Fifth streets, Waterloo. She was
stricken with apoplexy after sitting down for the
evening meal and before she had partaken of any
food. She died forty-five minutes later without re-
gaining consciousness. Dr. Hartman is almost pros-
trated by the unexpected visit of death in his home.
Dr. Thomas Gilmore Roberts, for the last year and
a half a resident of Davenport, died at 1 o’clock
April 22 at his home, 1920 East Fourteenth street,
after a lingering illness of six years’ duration. His
wife was formerly Aliss Laura Winkler.
VoL. XII, Xo. 6]
Journal of Iowa State Medical Society
241
Dr. Roberts was born in Groton, Vermont, Octo-
ber 18, 1850, and was a graduate of the Iowa State
University and State University of Missouri at St.
Louis.
Claude A. Power, son of Andrew and the late
Viola Power, was born in Pulaski, Iowa, on Sep-
tember 14, 1879. Here he grew into boyhood, young
manhood and manhood and lived in this community
until the day of his decease. As a boy he attended
the public school of Pulaski, and later attended and
graduated from the Southern Iowa Normal School
located at Bloomfield, Iowa. He also took some
studies at Drake University at Des ^Moines. He
spent about four j-ears teaching in the Iowa public
schools, part of the time in Pulaski. In 1909 he
graduated from the Iowa State University iMedical
School and after taking one year of interne work in
the Flower Hospital in New York Citj^ he returned
to Pulaski and opened up his office for the practice
of medicine. Here he enjoyed a prosperous practice
until, because of failing health, he was compelled to
relinquish his active practice in the last week of
July, 1921. Since that time he was able to do only
office practice and that only for a part of the time.
Failing health kept him confined to the house most
of this time to his bed. In the hope that he might
receive relief and help, he was taken to the Graham
Hospital in Keokuk on March 9 last and there made
a valiant fight against the inroads of his disease.
With the best of care, the struggle was a losing
one and his end came suddenly on Saturday morning,
April 22, 1922.
Dr. B. H. Criley, formerly known in Iowa medicai
circles died at his home in Los Angeles, California,
January 10, 1922 of apoplexy at the age of seventy-
one years. He was born in Downington, Pennsyl-
vania. In 1871 he located in Dallas Center where he
practiced until about 1914 when after more than
forty-three years’ successful practice, feeling the
necessity of a less strenuous life and more rest in a
more congenial climate, disposed of his professional
interests and moved to Los Angeles. Those of a
generation of physicians now, rapidly passing re-
member Dr. Criley as a most genial associate and
companion and one of high professional ideals. Sor-
rowing him is his widow and one son Dr. Clarence
Criley of Los Angeles.
From newspaper sources, we learn that Dr. Daniel
W. Layman a graduate of Drake University and of
Chicago University died in San Diego, California,
about February 20, 1922. Dr. Layman was born in
Des Moipes and practiced medicine in Marion, Iowa,
for several years.
Dr. J. S. Wailes of ^Mystic, a pioneer Appanoose
county physician died at the home of his daughter,
Mrs. Charles Mornson, April 16, 1922.
Dr. T. N. Bogart, the well known physician at
Excelsior Springs, Missouri, was found dead in his
office -April 1. Death due to apople.xy.
Doctor Herman A. Richter was born in New York
City on May 7, 1867, and died in the early morning
of March 16, 1922. He thus reached the age of
fifty-four years, ten months and nine days.
The deceased spent his early childhood in the
plate of his birth and there began to attend school.
When twelve years of age he moved with his parents
to Boyonne, New Jersey, where he continued his
schooling in the grade schools and thereupon fin-
ished his course in the high school of that city.
Soon after he attended the State University of
New York, where he finished the medical course of
said institution, graduating in 1891.
He began his practice of medicine in Bayonne,
New Jersey. Then he practiced for a time in Scran-
ton, Pennsylvania. In the spring of 1895 he came to
Klemme, Iowa, where he continued his practice for
the following seven years, then moved back to
Scranton, Pennsylvania, for a short time. In May,
1902, he removed to Garner, Iowa, where he lived
since.
Dr. Joseph MacDonald, managing editor and pub-
lisher of American Journal of Surgery, and co-pub-
lisher of Medical Pickwick, died suddenly in his of-
fice on January 7, 1922 of cerebral hemorrhage, at
the age of fifty-one.
Dr. MacDonald was born in Branchville, New Jer-
sey, in 1870. He spent manj' years in medical jour-
nalism. He rose from office boy to manager in the
office of the International Journal of Surgery. In
1905 — meanwhile having received his degree in medi-
cine— he resigned from that position to establish the
Surgery Publishing Company and the American
Journal of Surgery (formerly the American Journal
of Surgery and Gynecology). From the outset he
associated with himself a New York surgeon. Dr.
Walter M. Brickner, as the editor-in-chief. Dr.
AlacDonald was ex-president and, for many years,
secretary of the American Medical Editors’ Associa-
tion, an organization in which he was deeply inter-
ested and in whose affairs he was an active and
earnest factor.
He was an officer in the Medical Reserve Corps
of the United States Army since 1909. Upon our
entrance into the war he was commissioned a cap-
tain and, in December, 1917, a major. Later he was
appointed a member of the General Medical Board
at Washington.
A few months after his discharge from the army
in 1919, Dr. MacDonald suffered a cerebral hemor-
rhage causing a hemiplegia, from which he recovered
largely by dint of plucky perseverance — a character-
istic that dominated all his activities. He was a hard
worker and extremely energetic. He was always
genial, frank and optimistic.
242
Journal of Iowa State Medical Society
[June, 1922
Dr. ^MacDonald had a magnetic personality. He
had a host of friends, within and without his profes-
sion, who will mourn his early death. -He is survived
by a wife and sister, Airs. W. C. AIcKeeby, wife of
Dr. AIcKeeby of Syracuse, New York. — New York
Aledical Journal, February 1, 1922.
Pearce Bailey, New York City; College of Physi-
cians and Surgeons of Columbia University, New
York City, 1889, died at his home, February 11, from
pneumonia, aged fifty-seven. Dr. Bailey was grad-
uated from Princeton University, in 1886, and fol-
lowing his medical graduation studied abroad, much
of the time in France. He was adjunct professor of
neurology at Columbia University, from 1906 to 1910,
and consulting neurologist to St. Luke’s, Roosevelt,
New York and other hospitals. Dr. Bailey was a
member of the editorial board of the Archive of
Neurology and Psychiatry; he contributed exten-
sively to medical periodic literature and was author
of Accident and Injury; Their Relation to Disease
of the Nervous System, published in 1898. During
the war he served as colonel, AI.C., U. S. Army, in
charge of the neuropsychiatric division in the Sur-
geon General’s office, in recognition of which he re-
ceived the distinguished service medal. He was a
former president of the American Neurologic Asso-
ciation; chairman of the New York State Commis-
sion for Alental Defectives; one of the founders of
the New York Neurologic Institute, and originator
of the Classification Clinic recently established in
New York City for determining medical efficiency
and aptitude of young men for various vocations.
Dr. Bailey, while devoting himself to one of the
medical specialties, was a man of public spirit and
broad vision.
George Noble Kreider, Springfield, Illinois, medi-
cal department of the University of the City of New
York, 1880; former surgeon of St. John's Hospital;
died, January 4, aged sixty-five. Dr. Kreider was
born in Lancaster, Ohio, October 10, 1856, and re-
ceived his A.B. and A.AI. from Ohio Wesleyan Uni-
versity; was a surgeon in charge of the Wabash
Hospital; treasurer, 1891-1901, and president 1901 of
the Illinois State Aledical Society; founder and editor
of the Illinois State Aledical Journal; president of
the Sangamon County Aledical Society, 1899; lieu-
tenant-colonel and assistant surgeon-general of the
Illinois National Guard. For several years he served
on the Illinois State Board of Health. — Journal of
A. AI. A.
Dr. Pierre McDermid died at his home in Fon-
tanelle, Alarch 23, 1922, after a short illness of less
than two days, from apoplexy at the age of forty-six
years, three months and nineteen days.
Dr. AIcDermid was born in Fontanelle, December
4, 1875, the son of Dr. Peter and Anna H. Hethering-
ton AIcDermid. He received his preliminary educa-
tion at Simpson Academy, graduated in medicine at
Drake Aledical School 1894 and from Rush Aledical
College 1898, served an internship in St. Joseph’s
hospital, Chicago, one year.
In 1900 Dr. AIcDermid went to Europe and con-
tinued his studies in London and Edinburgh. He
was active in politics being affiliated with the demo-
cratic party and in 1914 was elected to represent
Adair county in the state legislature.
When the United States entered the World War,
he was one of the first to offer his services and was
commissioned a lieutenant in the Aledical Corps.
Soon on account of failing health, he resigned and
returned home.
Dr. AIcDermid was a member of the Adair County
Aledical Society, of the Iowa State Aledical Society
and a Fellow of the American Aledical Association.
He was active in Alasonic circles, was a member of
Des Aloines Consistory Scottish Rite Alasons.
Dr. AIcDermid had gained an enviable reputation
as a physician and surgeon and occupied a high posi-
tion in community in which he practiced. His death
is felt as a personal loss in Adair county.
Frederick Angier Spafford, Flandreau, South Da-
kota, Dartmouth Aledical School, Hanover, 1879; sec-
retary of the South Dakota State Aledical Associa-
tion; member of the board of regents. University of
South Dakota of Aledicine, Vermilion; served during
the World War as senior medical advisor of the
state; Indian Service; died recently, aged .sixty-six,
from heart disease.
Harry R. Layton, AI.D., Leon, Iowa, College of
Physicians and Surgeons, Keokuk, 1874. Died at his
home in Leon, Alay 1, 1922, age sixty-nine. Alember
Decatur County and Iowa State Aledical Societies.
Leading physician and surgeon in Decatur county
for forty-eight years.
Resolution of the Tama County Medical Society
Upon the Death of Mrs. Mary Walter, Wife of
Dr. A. F. Walter
Whereas Providence has removed from the home
of Dr. A. F. Walter, -of Gladbrook, Iowa, his wife.
Airs. Alary Walter, therefore be it resolved:
That we extend to him and his family our deepest
sympathy in the loss of an affectionate wife and lov-
ing mother:
Resolved, second, that a copy of these resolutions
be sent to him and family, that a copy be furnished
the Iowa State Aledical Journal, and that the resolu-
tions be properly spread upon the records of the
Tama County Aledical Society.
(Signed) G. T. AIcDOWALL,
GEORGE AIEYER,
Committee. .
Journal of Iowa State Medical Society
xiii
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When writing to advertisers please mention The Journal of Iowa State Medical Society
XIV
Journal of Iowa State Medical Society
BOOK REVIEWS
PROCCEDIXGS OF THE FIETEENTH AN-
NUAL MEETING OF THE ASSOCIATION
OF LIFE INSURANCE PRESIDENTS,
NEW YORK, DECEMBER 8-9, 1921.
Life insurance is unquestionably one of the most
important activities in our country. We are inclined
to look upon life insurance as a form of business in
which we are not interested except as we may get a
"job” of examining applicants from time to time. As
a matter of fact however, it is one of the most far-
reaching in its helpfulness of any business we know
of. It is a curious fact that an activitj' so helpful in
its operations should find it necessary to go out into
the field, and solicit insurance by the exercise of the
most persuasive methods possible, when men who
have family responsibilities remain indifferent, and
do not hasten as they ought to purchase at least a
moderated security for their dependents.
We are not referring to insurance as a business
investment but to insurance as a positive duty for
the protection of dependents. In this volume are
several valuable addresses which may be read with
great profit by physicians not examiners as well as
examiners, and also laymen of all classes.
NEOPLASTIC DISEASES
A Treatise on Tumors by James Ewing,
M.D., Sc.D., Professor of Pathology at Cor-
nell University Aledical College, New York
City. Second Edition, Revised and Enlarged.
Octavo of 1054 Pages with 514 Illustrations.
W. B. Saunders Company, 1922. Cloth,
$12.00 Net.
Three years ago the first edition of this import-
ant work appeared. It appeared to us at that time
after careful examination, that everything known
about neoplasms had been stated. In the past three
j'ears new enquires have been made without ma-
terially changing our conception of neoplastic
growths, particularly regarding the etiology of can-
cer. Ewald is quite at variance with Wilson and
McCarthy of the Mayo Clinic in relation to the as-
sociation of peptic ulcer with cancer. According
to the Mayo Clinic 68 per cent of ulcers are asso-
ciated with carcinoma. Ewald thinks that the higher
estimates above 2 or 3 per cent indicate too high an
average. In other countries, the estimate varies
from 3 to 50 per cent. Moutier in France finds in
thirtj'-five cases, nineteen simple ulcers and fifteen
cancer. Quite likel}' we will have to wait for an-
other generation for an agreement.
The relation of trauma to tumors has not changed
in the second edition and Ewing cites the attitude of
the French and German courts concerning the in-
fluence of trauma in causing tumor growths. The
enquirer seeking information concerning questions
in pathology will find what he is looking for in this
volume.
DISEASES OF THE SKIN AND THE ERUP-
TIVE FEVERS
Bj' Taj- Frank Sclamberg, M.D., Professor
of Dermatology and Syphilis. Graduate
School of Aledicine, University of Pennsyl-
vania, Fourth Edition, Thoroughly Revised;
Octavo 626 Pages, 265 Illustrations. W. B.
Saunders Company, 1921. Cloth $5.00 Net.
This interesting and highly practical book comes
to us for the first time and we are led to examine it
with much care. We are impressed at once with the
fact that not much space is devoted to elementary
anatomical and physiological facts with which read-
ers of medical books are presumed to be familiar.
The book is somewhat after the manner of a clinical
treatise. Definitions, sjmptoms, etiology, pathology,
diagnosis, prognosis and treatment.
A short chapter is devoted to Actinotherapy, Ra-
diotherapy, Opsonotherapy and Refrigeration and
the remainder of the book to Eruptive Fevers. The
main part of the book devoted to Skin Diseases; is
profusely illustrated, and furnish helpful aid in de-
termining the nature of the disease and convenient
formula are constantly furnished. If others have
found difficulty in making up combinations for skin
cases, they will appreciate with ourselves the com-
fort and convenience of referring quickly to some-
thing that we have lost or never acquired, that of
combining drugs. We say this at the risk of being
accused of being lazy or influenced by unscientific
methods.
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VoL. XII Des Moines, Iowa, July 15, 1922 No. 7
THE RELATION OF SPLENIC SYN-
DROMES TO THE PATHOLOCY OF
THE BLOOD*
W’lLLiA.M J. Mayo, ^I.D., Rochester, Minnesota
Many diseases have been named on the basis of
a purely symptomatic syndrome, the names beinjj
merely convenient hooks on which to hang a mis-
cellaneous assortment of obscure conditions. The
absence of definite etiologv' and jiathology, how-
ever, is somewhat compensated for by a rather
definite symptomatology which gives an appear-
ance of reality to obscurity.
For many reasons disease syndromes of the
spleen have been most remarkable in this re-
spect. The spleen is an organ, whose removal in
health causes no profound or permanent change
in the human economy, whose function, such as it
may be, is readily taken over by other organs or
tissues, but whose diseases, are cajiable, directly
or indirectly, of producing most [)rofound consti-
tutional changes which may lead to death.
A survey of these so-called splenic syndromes
should not be too closely concerned with the de-
tails. but it should rather be an attempt to obtain
a perspective of the phenomena as a whole. The
most interesting of the splenic syndromes are
those which concern the blood. The blood ma}'
be looked on as an organ in the form of fluid,
instead of a connective tissue medium, its func-
tion being to carry oxygen and food to the body,
to remove from them the ash and waste jiroducts.
and in addition to carry noxious agents of all
sorts which may gain entrance to the blood, to
the kidneys, mucous membrane, and skin for
elimination, or to the vital laboratories, of which
the liver is the chief, for defense. The spleen,
considered from this broader conception, is con-
cerned with the purification of the blood, and i>
one of the agents whereby worn-out red cells and
infectious or toxic material of various kinds are
filtered from the blood stream and directed to the
liver, the great metabolic and detoxicating organ
"Head before the annual assembly of the Tri-State District Me I-
ical Association, November 16, 1921
of the body. In other words, the function of the
. spleen and the pathologic misfortunes which it
sponsors, concern, chiefly, the blood stream. It
would a])])ear that the spleen is not the principal
agent, but that it is rather an organ of destruction
through which the principal agent works.
Always it is our desire to place our hands
definitely on a certain organ and say, “Here is
the trouble,” but indefiniteness lurks around the
sj)leen. Even when splenectomy results in alle-
viation of the symptoms, or in cure, we are by no
means convinced that the spleen was the cause of
the ailment. \Ve are only sure that by removing
it we have eliminated an organ of destruction or
perhaps broken a vicious circle. It is my purpose
at this time to speak of five syndromes in which
the s])leen may play a prima donna role. Four of
these, splenic anemia, jiernicious anemia, hemo-
lytic icterus, and polycythemia, concern the red
blood cell, and one splenomyelogenous leukemia,
concerns the white blood cell.
Splenic Anemia
Splenic anemia is a clinical entity. Its chief
characteristics are idiopathic enlargement of the
spleen and chronic progressive and intercurrent
anemia, with leukopenia. These are the ante-
cedents of phenomena related to portal circula-
tory obstruction, such as gastrointestinal hemor-
rhage and ascites, which eventually cause death.
If an attempt is made to study the clinical picture
of splenic anemia in its minutiie, it will be found
that the picture fades quickly, since the cause of
the condition is obscure and pathologically often
does not present distinctive characteristics; only
when the picture is seen as a whole and by ex-
clusion is a diagnosis possible.
.Since the publication of Osier’s article, in 1900,
the principal advances in the investigation of
splenic anemia have been made in connection with
the recognition of those conditions which, al-
though they simulate splenic anemia, have been
found to have a specific cause. Hemolytic ic-
terus, in which the jaundice is slight and intermit-
tent, had been confused with splenic anemia. Oc-
casional cases of pernicious anemia, in which the
244
Journal of Iowa State Medical Society
[July, 1922
spleen is greatly enlarged, had also been thus im-
properly classified, not because the resemblance
was striking, but because an enlarged spleen and
the anemia were regarded as characteristic of the
disease, and further investigation for the purpose
of making a correct diagnosis was not continued.
The splenomegalia of syphilis also is now rec-
ognized, and the enlarged spleens of chronic ma-
laria, chronic sepsis, tuberculosis, and Gaucher’s
disease have been removed from the splenic
anemia group as characteristic diagnostic fea-
tures have been recognized. Various competent
observers believe that von Jaksch’s disease (in-
fantile pseudo-leukemia) is the infantile form of
splenic anemia, in which the presence of a leu-
kocytosis and abnormal marrow cells may be ex-
plained by the transitional characteristics of in-
fants’ blood, von Jaksch’s disease is probably a
svndrome caused by various infantile disorders.
There still remains, however, a number of cases
in which the clinical picture of splenic anemia is
present, and the cause is unknown.
The chief pathologic conditions found in the
spleen in splenic anemia are generalized fibrosis,
thrombophlebitis, and atrophy of the pulp cells.
The deposits of connective tissue, endophlebitis,
and compression atrophy of the malpighian cor-
puscles, are not grossly different from those of
the splenomegalia of syphilis, malaria, and other
diseases of known origin, associated with fibrotic
spleens.
A patient with chronic fibrotic splenomegalia
who presents characteristics of chronic secondary
anemia, but who is not relieved by treatment, is
])otentiallv a sufferer from splenic anemia, and
will probably be cured by splenectomy without re-
gard to the cause of the disease. This has been
especiallv true of patients with sy])hilis and ma-
laria.
The REL.'niox of .Splenic Anemi.\ to B.\nti’s
Disease
In 1883, Banti described s])lenomegalia and
chronic anemia with cirrhosis of the liver. In
numerous communications since, he added va-
rious diagnostic criteria which have still further
obscured rather than clarified the subject. How-
ever, these criteria have made it possible to desig-
nate as Banti’s disease almost any form of spleno-
megalia accompanied by anemia and liver changes
in which a definite etiology cannot be established.
Moschowitz, in a critical analysis of Banti’s dis-
ease, came to the conclusion, with which I think
nearly all observers agree, that Banti’s disease
cannot be distinguished from splenic anemia, and
that what is ordinarily called Banti’s disease is a
terminal stage which may be found in some cases
of splenic anemia. That many patients die from
splenic anemia without liver changes is certain.
That some patients have cirrhosis of the liver at
an early stage of splenic anemia is also certain.
-\scites, without changes in the liver, may oc-
cur in splenic anemia. The mere presence, there-
fore, of ascites in connection with splenomegalia
is not sufficient to demonstrate that the liver is
at fault, although I believe it may be said that
anemia is not a marked feature of primary cir-
rhosis of the liver even if there is ascites, while
in s])lenic anemia it is an early and more or less
continuous manifestation. It seems probable that
certain as yet unidentified toxic agents strained
out of the blood by the spleen are responsible for
the fibrosis of the spleen, and the changes in the
si)leen, for the cirrhosis of the liver.
It is also known that the spleen acts as a filter,
removing bacteria from the blood stream, as m
typhoid and tuberculosis ; protozoa, as in syphilis
and malaria, and undoubtedly other noxious
agents. The spleen, unable to destroy these va-
rious substances, sends them through the splenic
vein to the liver for destruction, and the reaction
of the liver to chronic irritants is in the nature of
a connective tissue disease which we speak of as
cirrhosis, without regard to its cause. If the
sjdeen is unable to rid itself of all the material
that it filters from the blood stream, sequestration
of the filtrates may occur and give rise to the
\arious splenomegalias with assured etiolog}',
such as those due to the S pirochcta pallida, Plas-
modium malaricc, Bacillus typhosis. Bacillus tu-
berculosis, and to others which have as yet no
known etiology.
The spleen has differentiated and characteristic
cells. It is, therefore, capable of varied path-
ologic conditions. The liver has but one type oi
cell with different physiologic activities, and its
])rocesses are less varied. The reaction of the
liver to chronic irritation, which reaches it by
way of the portal system without regard to cause,
is usually a fibrosis which we call portal cirrhosi>.
The portal cirrhosis of Laennec does not vary
in type, whether produced by gin or pepper, or
whether it is found locally around areas of tu-
berculosis, gumma, or cancer. Usually cirrhosis
is diagnosed with the hobnail variety of Lsennec
in mind. Yet in my experience, accepting 1560
gm. as the weight of the average liver, the cir-
rhotic liver is as often enlarged as it is contracted.
.\s pointed out by Osier, the beer drinker and
others may have huge, smooth, cirrhotic livers, in
which the characteristic fibrosis is smoothed out
hv dejiosits of fat. On this assumption, there-
VoL. XII, No. 7]
Journal of Iowa State Medical Society
245
fore, it could be said, inferentially, that the type
of splenic anemia which is accompanied by cir-
rhosis of the liver and has been called Ranti’s dis-
ease is a condition in which the fibrosis of the
spleen and the fibrosis of the liver are due to the
same agent, that they have a common etiology,
and that the removal of the spleen when the dis-
ease is not too far advanced cures the anemia by
preventing excessive blood destruction and pre-
vents these toxic substances reaching the liver so
that the cirrhotic process in the liver itself is
checked, and the ascites disappears. We have pa-
tients, whose cases fulfilled this description, alive
and in good health for years following splenec-
tomy.
I have previously called attention to the fact
that there is another element of relief following
splenectomy which must be taken into considera-
tion. In the normal condition 25 per cent of all
the blood carried to the liver comes through the
splenic vein, while in enormously enlarged spleens
the splenic vein may be the size of the portal vein
The removal of the spleen in these cases relieves
the liver of an overload, and it then becomes able
to carry on its function without those evidences
of circulatory' obstructions that results in ascites
and hemorrhages. Splenectomy' may, therefore,
be looked on as equivalent to establishing an Eck
fistula or the condition we attempt to bring about
by establi.shing collateral circulation, after the
method of Talma, Morison and Drummond,
through the vascular channels of .Sappey, a condi-
tion described by Fagge as found with advanced
cirrhosis in some persons killed by accident while
in apparent health.
The changes found at necropsy' after death
from splenic anemia are not necessarilv to be
considered the condition that exists throughout
the whole course of the disease ; thev are to a
large extent terminal. All the patients operated
on who were not in an advanced stage of the dis-
ease recovered, after .splenectomy, and the ma-
jority' have remained well. We must, therefore,
look on ascites, edema of the lower extremities,
and cardiorenal decompensation as terminal con-
ditions which increase the dangers of operation,
^'et the spleen may be removed successfully even
in the terminal stage of the disease. We have
o])erated on a number of j»atients for splenic
anemia who had extensive cirrhosis of the liver,
many' of these of the Liennec type. Following
splenectomy' the ascites disappeared and the hem-
orrhages from the stomach stopped; the majoritv
who recovered from the operation are alive and
apparently well after .some years. The spleens in
cases of splenic anemia are usuallv adherent and
difficult to remove, and in the late cases when
endophlebitis and thrombosis are marked the dan-
ger of an acute thrombosis of the large vessels
of portal circulation is great. We have operated
on seventy-four patients w'ith splenic anemia of
unknown origin with nine deaths. This does not
include a number of splenectomies for splenic
anemia of known origin, such as syphilis.
Pernicious Anemia
'I'he etiology of pernicious anemia is unknown,
the early symjitoms are indefinite, and by the time
the diagnosis can be made the disease is incurable.
The disease may be described as a progressive de-
generation of the red blood cell or, more pic-
turesquely, a cancer of the red blood In contrast
to splenic anemia, which is of the secondary' type,
the blood picture in pernicious anemia has char-
acteristic cells which, more or less, identify the
di.sease. The color index, or hemoglobin percent-
age, is higher in proportion to the number of red
blood cells than in the secondary anemias. The
lemon color of the skin, sometimes with an ic-
teroid hue. is so different from the color of the
skin in the secondary anemia that .sometimes a
diagnosis is possible by looking at the patient.
This icteroid hue is more prominent in cases in
which hemolysis is marked, as shown by examin-
ation of the duodenal content after the Schneider
method. If we might assert that in cases of per-
nicious anemia in which hemolysis is most marked
patients have a greatly enlarged spleen or that the
spleen exhibits definite pathologic changes, we
would have succeeded in establi.shing a direct
connection between the enlarged spleen so often
found and the disease. Unfortunately, our ex-
perience does not su]>port this hypothesis, and the
size of the spleen does not seem to bear a definite
relationship to the severity' of the disease. X"e-
cropsy, after death from pernicious anemia, as a
rule, shows a small spleen, but in two only of our
cases was the s])lecn bc’ow normal weight at oper-
ation, and both were terminal cases.
The average weight of the spleens removed in
our cases of ])ernicious anemia was 400 gm.. ex-
clusive of two large spleens, one of which
weighed 2220 gm. and the other 1600 gm.. It
seems probable, therefore, that in pernicious
anemia the spleen is enlarged during the early and
middle stages, and that the contraction so often
found at necropsy is a terminal condition. The
question is as yet unanswered whether pernicious
anemia is a definite and specific entity, or whether
it is a terminal change of several conditions, and
recognized only' as pernicious anemia when the
patient has reached a stage which we know will
246
Journal of Iowa State Medical Society
eventually cause death. I have been struck with
the fact that after complete gastrectomy the pa-
tients have much the appearance of pernicious
anemia and even more striking is the resemblance
between anemias having their origin in certain
diseases of the proximal half of the colon and
])ernicious anemia.
Any form of treatment for pernicious anemia
may j)rove, or at least may appear, to be benefi-
cial. Even without treatment these patients have
their ups and downs and it is not an infrequent
clinical exj>erience to have a patient present him-
self with symptoms which might be construed as
being tho.se of an early pernicious anemia, an.l
then with or without treatment recover and re-
main well. In eliciting the history the physician
finds that the symptoms are often indefinite in
the earlier stages, before the blood changes be-
come characteristic.
Eppinger first suggested spleiyectomy as a cure
for pernicious anemia, and the earlv reports with
the abundant testimonv of temj)orarv relief were
quite sufficient to give the operation a fair trial
in this ho])eless disease. Considering the confu-
sion which so often attends the early diagnosis,
it seems probable that obscure cases of hemolytic
icterus and s]4enic anemia have been accidentally
included in the jiernicious anemia group. Re-
moval of the sjileen in such cases may have con-
tributed to the impression that sjdenectomy may
cure pernicious anemia. In the investigation of
our cases of splenectomy for pernicious anemia,
great, although usually temporary, impro\emeni
has been noted. There is gain in weight, and irn-
])rovement in the hemoglobin in the hlood from
an average of 38 to 72 per cent, and in the red
cells from 2,000,000 to 4,000,000. (fiffin aivl
Szlapka found that of fiftv patients with perni-
cious anemia for whom splenectomy had been
jierformed in the Clinic more than four years be-
fore 21.3 per cent lived more than three years,
and 10.6 ])er cent are still alive more than five
years. These patients have li\ed on an average
of two and one-half times as long as a compar-
able grou]) of non.s])lenectomized patients. It
would api)ear that the spleen did not, on its own
initiative, destroy the red cells, but that it acted
rather as the agent of destruction, and splenec-
tomy accomplished its ]>urpose .so far as it re-
moved the destructive agent, breaking up a vi-
cious circle, but ])robably not otherwise influenc-
ing the course of the disease. Evidently in per-
nicious anemia the patient is not able to produce
normal cells, but the cells are capable of function,
and splenectomy prevents their destruction. The
[July, 1922
cord changes are not greatly impro\ ed by splen-
ectomy.
In our experience in the cases in which the re-
sults were most favorable the symptoms were
those less characteristic of pernicious anemia. In
young and middle aged persons, in whom the dis-
ease is rapid, especially if hemolysis is known to
be marked, splenectomy is worthy of trial. On
the whole, it may be said that whenever perni-
cious anemia has developed to the stage in which
the blood is characteristic, it is probably incur-
able, and terminal splenectomy is to be regarded
as a means of palliation, and not of cure. \\’e
have splenectomized fifty-four patients with per-
nicious anemia with three deaths (5.5 per cent).
The three deaths occurred in the first nineteen
cases and were due to the fact that the patients
were operated on during crises in an exacerba-
tion of the disease. Since we have operated on
these patients only when they are on the up-
grade, as after transfusions of blood, we have
had no deaths in thirty-five cases.
Hemolytic Icterus
Hemolytic icterus has not been classified with
the anemias, but, as pointed out by Kanavel an l
Elliot, the peculiar splenic activity results in an
anemia which is the cause of death. The etiology
of hemolytic icterus, as of si)lenic and pernicious
anemia, is unknown.
A well developed case of hemolytic icterus
stands out with a vividness unequaled in splenic
anemia or in pernicious anemia. These three dis-
eases, all of unknown etiology and lacking sound
pathologic foundation, when examined in detail
are without distinctive features. \’iewed in the
perspective thev are outstanding clinical entities.
I'he characteristic features of hemolytic icterus
are an enlarged spleen, chronic jaundice with e.x-
acerbations. normal bile colored stools, and ab-
sence of bile in the urine.
It is certain that in hemolytic icterus the spleen
destroys, unnecessarily, the red cells; the enlarge-
ment of the spleen may be in the nature of a
work hypertrophy. Enlargement of the liver is
usually present and may also be a work hyper-
trophy. In some of our cases sections from the
liver showed definite hyjierplasia of the cells.
-Sixty per cent of our patients splenectomized for
hemolytic icterus had gallstones due to the great
amount of pigment which inundates the liver
from the destruction of the red cells. As these
gallstones may cause infection of the biliary tract,
obstruction, and so forth, a very confusing clini-
cal picture results, which the history and enlarged
spleen must be relied on to clear up.
VOL.XII, No. 7]
Journal of Iowa State Medical Society
247
Thei'C are two types of hemolytic icterus, the
familial or congenital type of Minkowski, and the
accpiired type of Hayem and M’idal. In the
familial tyjie the disease may be noticed from in-
fancy and it may not be progressive ; the patients
live the allotted span of years in a fair degree of
health, but with more or less jaundice throughout
life. These cases are not uncommon and are to
be seen in every community ; in many instances a
more serious condition develops which makes
them indistinguishable from the acquired type,
and like the acquired type, the disease progresses
in the course of some years to a fatal ending.
Chauffard and Widal have pointed out that the
red cells are less resistant in hemolytic icterus
than normally, and our experience confirms these
observations. Sanford has worked out a simple
and very reliable method for testing the fragility
of the red cells; this is being used in the Clinic
extensively and with great satisfaction. We have
removed the spleens from thirty-seven patients
with hemolitic icterus with one death. This pa-
tient was operated on during a crisis ; this death
should not have occurred.
Polycythemia
Polycythemia (rubra vera) is the opposite of
anemij^ and signifies a condition of the blood in
which the number of red cells is decidedly in ex-
cess of normal. This excess is constant and not
due to temporary dehydration, such as sometimes
results from diarrhea or profuse sweating, but de-
pends on organic changes in the hemopoietic sys-
tem, the nature of which is little understood. In
polycythemia the red blood cells may reach from
8,0CK),(XX) to 12,000,000 and the hemoglobin may
reach as high as 130; the increased viscosity of
the blood causes the patient to present an ap-
pearance of cyanosis. The pathology of this dis-
ease is obscure, but one characteristic feature is
the enlargement of the spleen. Heretofore, the at-
tempt, based on what we know of the physiology
and pathology of the spleen, to connect the spleen
definitely with this syndrome, has failed, and the
splenomegalia has been looked on as an incidental
rather than an etiologic factor in polycythemia.
This interpretation is still further borne out by
the fact that when death occurs other organs
show changes of a somewhat similar nature to
those in the spleen. Yet the enlargement of the
spleen is suspicious, and the history of medicine
is the graveyard of dogmatic attempts to substi-
tute postmortem pathology of terminal conditions
for the pathology of the living.
Gastric hemorrhages are one of the occasional
signs of polycythemia, and in the anemic condi-
tions which result, the spleen is reduced in size
and the blood does not exhibit the characteristics
of polycythemia. When the symjitoms of the dis-
ease are re-established there is coincident enlarge-
ment of the spleen.
Polycythemia was described by \'aquez, in
1892, and in an early period Osier added greatly
to our knowledge of the subject. If we accept
the opinion of some careful observers who believe
that the spleen not only destroys abnormal red
cells, but also, to a considerable extent, controls
through some internal secretion the productivity
of the red cells of the bone marrow, we might
explain the phenomena of polycythemia on the
hypothesis that the spleen failed to destroy tin*
normal number of red cells and produced a hy-
peractivity of the bone marrow.
In the Clinic, we have .seen a few patients with
ipolycythemia ; one patient with an undoubted
polycythemia was splenectomized shortly after
recovery from a severe hemorrhage. The spleen
weighed about OOO gm. General abdominal ex-
jrloration did not show any remarkable pathologic
condition outside the spleen. A section from the
liver did not show hepatic disease. Following
splenectomy^ the patient has regained his health to
a remarkable extent, and all signs of polycy-
themia have disappeared. I'he time has been too
short for us to know whether this remarkable
transformation is permanent, but it leads to the
thought that the spleen may be more closely con-
nected with the disease than had been supposed
and that splenectomy may, in certain cases, be in-
dicated.
Leukemia
If there has been any one condition believed to
be nonsurgical and incurable, it is splenomyelo-
genous leukemia. The theory has been that at
least 99 per cent of patients operated on for the
disease would die as a result of the operation, and
that the one who lived would not be benefited.
Tet we have long known of therapeutic agents
(benzol, x-ray, and so forth), which reduced the
size of the spleen and, as might be expected, also
improved the condition of the blood. With the
use of radium, which could be applied readily
over the area of the spleen, a vast change came
about in the therapeusis of splenomyelogenous
leukemia. I do not know of any clinical expe-
rience that is more striking than the good result
which follows the application of radium over a
huge leukemic spleen. Many times the spleen
shrinks so much as to disappear below the left
costal margin, and the white cells decrease from
hundreds of thousands to below 10,000. I have
even seen leukopenia produced, the white cells
248
Journal of Iowa State Medical Society
[July, 1922
decreasing from 600,000 to 3,700 in five weeks.
Witli this extraordinary reduction in the size of
the spleen and the reduction in the number of
white cells an equally extraordinary improvement
in the anemia takes place, and the patient is mar-
\ elously benefited. As the spleen again gradually
increases in size the white cells increase, the red
cells decrease, and the patient loses ground. It is
well to eliminate all of our presumptions con-
cerning this disease and to pause for a moment
in perspective. Have we, in considering opera-
tion in this condition, as in so many other in-
stances, allowed tradition to hamper progress?
My first experience in splenectomy for spleno-
myelogenous leukemia was with a patient who
came to the Clinic with a greatly enlarged spleen,
a white cell count of 300,000, and a history of
having had the disease for two years. There had
been great improvement under x-ray treatment ;
at one time the white cells were reduced by it to
below 50,000, but, as regularly happens, the x-ray
had finally lost its effect, and the patient’s con-
dition on examination was worse than it had been
at any former time. The patient herself was
greatly impressed with the definite connection be-
tween the size of the spleen and her condition,
and was anxious to have the spleen removed. I
operated and the patient recovered from the oper-
ation uneventfully. Within ten days the white
cells had dropped to less than 40,000 and she was
greatly improved. She lived in good health
more than two years following the splenectomy.
On the basis of this experience, we have in a
number of instances reduced the size of the
spleen with radium until the blood count approx-
imated the normal, and then removed the spleen.
We ha^•e splenectomized twenty-nine patients for
splenomyelogenous leukemia with one operative
death. This patient died from pulmonary em-
bolus fourteen days after operation. Seven of
these twenty-nine patients are known to be alive
and in good condition more than three years fol-
lowing operation, four more than four years, and
one more than five years. I can not believe that
these patients are cured, but the experience has
been interesting and suggestive.
It is possible that we recognize leukemia as a
disease only after it has reached the hopeless
stage, or that it is a terminal condition of a much
more common, although unrecognized, malady.
These are interesting problems which can not
now be answered. Leukemia has been called a
cancer of the white cells. The leukemic spleen
is not adherent, as a rule, and after it is reduced
bv radium is removed readilv.
BIBLIOGRAPHY
1. Banti. G. ; Dell’ anemia splenica. Arch. d. Scuola d’anat.
patoi., Firenze. 1SS3. ii, 53-122.
2. Chauffard, ; Pathogenic de I’ictere congenitale de
I'adult. Semaine med., 1907, xxvii, 25-29.
3. Dock, G. and W'arthin, A. S. : A clinical and pathological
study of two cases of splenic anaemia with early and late stages
of cirrhosis. .Am. Jour. Med. Sc., 1904, cxxvii, 24-55.
4. Elliott, C. and Kanavel, A. B. ; Splenectomy for
haemolytic icterus. Surg., Gynec. and Obst., 1915. .xxi, 21-37.
;>. Eppinger, 11.: Zur Pathologic der Milzfunktion. Bcrl.
kiln. Wchnschr., 1913, 1, 1509-1512; 1592-1596; 2409-2411.
6. Fagge, C. H. : Principals and practice of medicine. Phil
adelphia, Blakiston, 18S6, 883 pp.
7. Giffin, H. Z. : Splenectomy for splenic anaemia in child,
hood and for the splenic anaemia of infancy. .Ann. Surg., 1915
Ixii, 679-687.
8. Giffin, H. Z. and Sanford, .A. H. : Clinical observations
concerning the fragility of erythrocytes. Tour. Lab. and Clin.
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9. Giffin, H. Z. and Szlapka, T. L. : The treatment of per-
nicious anaemia bv splenectomy. Second report. Tour .Am
Med. .Assn., 1921, Ixxvi. 290-295.
10. Hayem, G. : Sur une variete particuliere d’ictere chro.-
nique: ictere infectieux, chronique splenomegalique. Presse med.
1898, vi, 121-125.
11. Hayem, G. : Xouvelle contribution a I'etude de I’ictere
infectieux chronique splenomegalique. Bull, et mem. Soc. med
d. hop. de Paris, 1908. 3 s., .xxv, 122-140.
12. Minkowski: Uber eine hereditare, unter dem Bilde eines
chronischen Icterus mit LTrobilinurie, Splenomegalie, und Nue-
rensiderosis verlaufenden .Affection. Verhandl. d. deutsch. Cong,
f. inn. Med., 1900. xviii, 316.
13. Aloschowitz, E. : .A critique of Banti’s disease. Jour
.Am. Med. .Assn., 1917. Ixix. 1045-1051.
14. Osier, W. : On splenic anaemia. .\m. Jour. Med. Sc..
1900, cxix, 54-73.
15. Osier, W.: Chronic cyanosis, with polycythemia and
enlarged spleen; a new clinical entity. .Am. Tour. Med. Sc.,
1903, cxxvi, 187-201. .Also: Tr. .Assn. .Am. Phys., 1903, xviii,
299-325.
16. ^ Osier, A\ . and Alcf'rae, T.: Alodern medicine. I’hila-
delphia. Lea and Febiger, 1914.
17. \ aiiuez. H.: Sur une forme speciale de cyanosc s'ac-
compagram d’hyperglobulie excessive et persistante. Bull, med
Paris. 1892. vi. 849.
IS. A\ arthin, .A. S. : The relation of thrombophlebitis of the
portal and splenic veins to splenic anaemia and Banti’s disease.
Internat. Clin., 1910, 20 s„ iv. 189-221.
19. Widal, F., .Abrami, F. and Brule, M.: Differenciation de
plusieurs types d’icteres hemolytiques par le precede des hematies
deplasmatisees. Presse med., 1907, xxv, 641-644.
THE DI.\GXOSIS OF FOREIGN BODIES
IX THE BROXCHI*
Thomas McCrae, ^I.D., Professor of Medicine,
Jefferson ^ledical College, Philadelphia, Penn.
My object is not an endeavor to discuss all the
jihases of this subject but rather to bring before
you certain points in the symptoms and signs
which bear particularly on the diagnosis of for-
eign bodies in the hronchi. You may regard the
subject as belonging to the curiosities of medicine
rather than to every day work, but there are many
cases of foreign bodies in the bronchi which are
unrecognized and no one knows when he may
meet a case. The number of patients who have
carried a foreign body for years without any sus-
picion of the fact is a proof of the frequency with
which they are missed. .A. great deal of gratitude
is due Chevalier Jackson both from patients and
•Presented at the Tri-State Medical Association, Milwaukee,
Xoveinber, 19’21.
^'0L. XII, No. 7]
Journal of Iowa State Medical Society
249
from members of tlie profession. He has saved
many patients and instructed us on a subject of
which we knew little.
First in the question of diagnosis is the need of
having the possibility of a foreign body in a
bronchus in mind in the investigation of every
]>uzzling case of respiratory disorder. If this is
done and the matter considered it is evident that
the chances of correct diagnosis are increased.
If it is not thought of, only some additional evi-
dence, such as from an x-ray examination, mav
set us right, but this only in the case of foreign
bodies which show in an x-ray plate. Probably
15 per cent of all foreign bodies do not and it is
for the recognition of these the study of the
symptoms and signs is so important.
History — It is striking in going over the his-
tories, especially in the cases of long duration, to
note how little attention was paid to this in some
instances. For example, one child insisted that
she had aspirated a foreign body but no one paid
any attention to her story. A recurring cough
received little attention until its becoming almost
constant many years later suggested an x-ray ex-
amination which proved the truth of her state-
ment. This inattention is perhaps partly due to
the lack of recognition of the fact that a foreign
body may be aspirated into the larynx with com-
paratively little distress or disturbance. There
are numerous instances in adults in which they
knew what had occurred and were able to give
an account of the symptoms, which may not be
severe. In other cases there is not the least sug-
gestion in the history which gives any clue as to
the time of aspiration. In young children there
mav be no ixissibility of getting any history if the
child was alone at the time of aspiration. Care-
ful enquiry may give a clue and in the case of the
most deadly of all foreign bodies — the peanut —
it is often possible to find that the child had been
given or obtained a peanut. Evidently a history
of cough dating from the extraction of teeth un-
der anesthesia is significant.
Symptoms — These must vary with the char-
acter of the foreign body and all grades from
slight discomfort with some cough to symptoms
of great severity may result. A safety-pin in a
bronchus may give few symptoms, but a seed or
a nut in the trachea or a peanut in a large bron-
chus may cause the most acute respiratory dis-
tress. There are all variations from slight dis-
comfort to the most severe dyspnoea. At the
time of and shortly after aspiration there may be
discomfort or pain and paroxysms of cough.
These may be of short duration if the object
passed into a bronchus, but should it remain in
the trachea var}'ing grades of obstruction occur
and conse(iuently varying symiitoms. It is con-
venient to separate the .symptoms of what may be
termed acute cases fnmi those of longer dura-
tion, which may be called chronic. The symp-
toms in acute cases may he largely mechanical,
due to marked obstruction in the laiwnx and
trachea or to irritation set up by the foreign body
with resulting swelling and obstruction. The me-
chanical symptoms require no discussion as their
nature is evident. The symptoms due to irrita-
tion are shown in the peanut cases in which a
most intense purulent laryngo-tracheo-bronchitis
results. Here the picture is of an acute respira-
tory tract inflammation with dyspnoea and dis-
tress.
In the chronic cases the symptoms are such as
result from a local lesion which may irritate a
bronchus or partially or completely plug it. Cough
is invariable, slight or marked, constant or par-
oxysmal depending on the condition. Should ab-
scess or bronchiectasis result the usual symptoms
result. Pain is not necessarilv prominent but
may be fairly marked.
General Features — These evidently will vary
with the character' of the foreign body, the
changes it has produced and the complications.
A safety-pin may give no general features while
an object which plugs a bronchus may be accom-
panied by infection or bronchiectasis followed by
an abscess. Hence there is no one description
which can be given. What may be termed the
\en' acute cases — as from the aspiration of a
]>eanut — show the picture of a very intense
toxaemia with features suggestive of a general
acute respiratory tract infection. The cases in
which a body is aspirated but does not plug a
bronchus may give very little in the way of gen-
eral disturbance. Chronic cases show features
dependent largely on the secondary changes, such
as purulent bronchitis, abscess and bronchiectasis-
Fever — This is frequent and may show many
variations. ,\n irregular curve is common both
in acute and chronic cases. In the latter the
cur\e is that of sepsis with frequently a large
excursion in the twenty-four hours.
Dyspna-a — In the acute cases this is extreme
and may suggest laryngeal diphtheria, a probable
error as there may be considerable laryngeal ob-
struction. The height of the fever is against this
diagnosis. In the less acute cases there may be
dyspnoea only on exertion or movement. In chil-
dren the act of crying or a change in position may
bring on dyspnoea.
Cyanosis — This may be extreme in the acute
cases but is rarelv marked otherwise.
250
Journal of Iowa State Medical Society
[July, 1922
Clubbed Fiiu/crs — This is a common change in
long continued cases but differs in no way from
that due to any chronic thoracic septic process.
Growth — In children with a foreign body pres-
ent for some time there may be marked inter-
ference with growth. In such cases there is
usually sejitic absorption.
The physical signs which are most importam
may be summarized as follows :
1. Inspection — In eyery' case seen by me there
has been definite diminished expansion on the al-
fected side. If the foreign body has shifted fnan
one side to the other or is situated at the bifurca-
tion of the trachea the expansion may be de-
creased on both sides. In some cases in whicii
the foreign body was a ]>in, decreased expansion
was the only sign. If the foreign body has acted
as a yahe and allowed air to enter but not to
escape, the affected part of the lung will be dis-
tended and that part of the thorax be fuller — but
the expansion is less. The extent of moyement
of the diaphragm is important to note.
2. Palpation — The yocal fremitus varies with
the condition ])resent. If a bronchus is completely
plugged, vibrations will be absent over the sup-
plied portion of lung. If the closure is intermit-
tent the vibrations may be absent at one time and
presait at another. If the bronchus is partially
obstructed, there may be a decrease in the vibra-
tions. In young children it may not be possible
to gain much information from the study of the
fremitus.
3. Percussion — Evidently the findings must
vary greatly. With a ball valve action of the for-
eign body the affected portion of lung becomes
markedly emphysematous and hence yields hyi^er-
resonance or tympany. \\ ith complete plugging
of a bronchus there will be flatness over the af-
fected portion of lung as soon as all the con-
tained air is absorbed. If the plugging is not
constant there may be some resonance at one time
and none at another but there is usually some
grade of dullness. The sense of resistance will
vary with the condition present. M’ith collapse
of a jiortion of lung there is likely to be tyinjiany
for a time. There may be varying grades of com-
binations of dullness a,nd tympany, especially in
children, in whom hyjierresonance and tympanv
are common. 'These are often very confusing,
but a careful com])arison with the note elsewhere
will usually les.sen the difficulty.
4. .luscultation — The most diverse findings
are to be ex])ected and the signs may vary from
hour to hour if the bronchus is not com])letel,
plugged. 'The degree of colla]>se of the lung,
the amount of contained air and fluid, the extern
of fibroid change, the presence of abscess or-
lironchiectasis, all influence the signs. Over a
lobe, the bronchus of which is completely
plugged, as a rule the breath sounds are absent
but occasionally, and especially in children, dis-
tant breath sounds may be heard. Over the portion
of lung sui)])lied bv a partially obstructed bron-
chus, the breath sounds are harsh and rough with
])rolonged exjviration, accompanied by many rales,
usually coarse, sometimes bubbling and with both
inspiration and expiration. Over other parts of
the lung of the affected side and on the other side
the findings depend on the amount of irritation
set u]) and the |)resence of secretion. Rales may
be heard everywhere in the acute cases.
There are several sj)ecial points worthy of no-
tice.
1. With some foreign bodies in the trachea,
such as a melon seed, there may be very curious
sounds ])roduced, quite unlike other sounds con-
nected with the respiratory tract, and very sug-
gestive of the diagnosis. These sounds have a
flapping quality.
2. In some cases in which there was a small
metallic foreign body in a bronchus, not suffi-
ciently large to cause any marked obstruction,
very fine rales of a curious character have been
heard. These have been described as “tissue
l)aper” rales, and are such as might be produced
by the movement of the finest grade of tissue
l)a])er. They have been heard at the end of in-
spiration and are much finer than the fine crepi-
tations heard at the early stage of lobar pneu-
monia. On a hasty or careless examination the\-
are so fine that they would not be heard. I have
never heard similar rales in any other condition.
Naturally one hesitates to say that these are ab-
solutely peculiar to a small metallic foreign body.
3. The “asthmatoid wheeze.” This is a sign
of considerable value if present, but no weight
should be placed on its absence in excluding for-
eign body. I'his is a wheezing sound which mav
be heard usually close to the open mouth of the
patient, either by listening with the ear, or some-
times if the bell of the stethosco])e is held close to
the mouth. It is usually brought out best by hav-
ing the ]>atient make a forced ex]>iration. The
wheeze \ aries a great deal in loudness ; sometimes
it can be heard at a considerable distance from
the patient. If present, it is usually most marked
during expiration.
There are certain occurrences which may mod-
ify the clinical features and cause difficulty in
diagnosis. ,\mong these are :
1. Change in Position of the Foreign Body—
If the object has been on one side for a time and
\^0L. XII, Xo. 7
Journal of Iowa State Medical Society
251
then is dislodged, reaches the trachea and goes
down a bronchus of the other lung, a very puz-
zling set of signs results. A foreign body may be
dislodged, reach the trachea and then be caught
at the bifurcation, giving rise to signs on both
sides. In the absence of any history of a foreign
body, the diagnosis may be very difficult for some
days as signs persist on the side first involved.
2. Symptoms Due to Secretions — Evidently
these may reach other bronchi than the one af-
fected, or be carried over to the bronchi of the
opposite side. The signs of a foreign body are
found on the affected .side and those of a varying
degree of bronchitis in other lobes or in the other
lung. Difficulty may come from a foreign body
in the resophagus causing secretion which is car-
ried u{) and passes into the trachea, usually set-
ting up a diffuse bronchitis.
3. Prex’ioiis Bronchoscopy — If this has not
been skillfully done, there may be considerable
trauma and when the patient is seen later it may
be difficult to say which signs are due to it and
how much to a possible foreign body. I have
seen recentlv two patients with Dr. Jackson in
whom broncho.scopy (done elsewhere) had
caused severe trauma and in whom we were never
able to find any evidence of a foreign body. In
both these cases the foreign body was supposed
to be a substance which would not show in the
x-ray plate. The chief aid in diagnosis in these
cases, is in waiting until the symptoms and signs
due to the bronchoscopy have had time to disap-
pear.
Rare accidents may give very complicated pic-
tures. Following bronchoscopy ( done elsewhere)
jmeumothorax occurred on the affected side. As
this foreign body was one which did not show in
the x-ray plate, the difficulties of diagnosis are
evident. Even before the air was absorbed it was
possible to be fairly sure of the condition by x-ray
study.
^Mention should be made of special groups of
cases in which the diagnosis is most often missed.
Arachidic Bronchitis — Drs. Jackson and Spen-
cer have used this term to designate bronchitis
which follows the aspiration of a nut, especially
a peanut. The severity of the symptoms is in in-
direct ratio to the age. It is a very severe and
dangerous condition in young children, which
may be mistaken for laryngeal cHphtheria, infec-
tive laryngotracheitis (from some cause other
than a foreign body) or broncho-pneumonia. The
absence of breath sound over a lower lobe has
led to the diagnosis of empyema. The children
are usually verv- ill, showing dyspnoea and rest-
lessness, often extreme toxaemia, cyanosis, severe
cough, sometimes j)aroxysmal, and possibly a
pink tenacious purulent sputum if the child is old
enough to ex{>ectorate. The picture is suggestive
of a very severe broncho-pneumonia, often with
evidence of laryngeal obstruction due to the local
swelling. 'I'he signs of obstructed inspiration may
be marked. In some cases the cyanosis is suc-
ceeded by pallor, suggesting circulatory failure.
The “asthmatoid wheeze” is often present. Theie
is high irregular fever with a rapid pulse and
respiration rate. T he thorax shows asymmetry,
as the affected side is often over-distended but
it shows less respiratory movement. Percussion
o\er the affected side may show hyper-resonance
or tyfnpany, if the lung is over-filled with air
(ball-valve action). On auscultation the breath
and voice sounds are decreased or absent over the
affected lung. Many rales, usually loud and
coarse, sonorous and sibilant are heard, and they
may be equally numerous and loud on both sides.
1 he diagnosis of hroncho-pneiimonia may be
suggested but the evidence of involvement of one
lobe or one lung, the aEsence of dullness, the
breath sounds being harsh but not tubular, and
the absence of fine rales should prevent this mis-
take. From laryngeal diphtheria, the high fever,
the negative bacteriological examination, the fact
that the voice is not lost, the presence of local
signs in one lobe or lung should assist. When
there are marked signs in a lower lobe, due to the
bronchus being plugged, the diagnosis of em-
pyema has been made but the signs elsewhere,
the absence of the resistance so characteristic of
empyema, the area of dullness (corresponding to
a lobe) and an x-ray study should prevent this
error. The use of the needle should rarely be
necessary. Infective laryngo-tracheitis may
cause difficulty, but the absence of any local
signs pointing to involvement of one lobe or one
lung should soon settle this question. Emphasis
is laid on the value of inspection as showing local
change.
Some of the cases in which seeds have been
aspirated give great difficulty. If they plug a
bronchus there should be comparatively little dif-
ficulty, but a small seed or a small portion of a
nut may only partially obstruct. An example is
under observation at the time of writing. A child
aged twenty-seven months aspirated portions of
an almond nut. Dr. Jackson removed one portion
from the bifurcation of the trachea and another
from the left main bronchus. There was a very
intense laryngotracheitis which required tracheot- ’
omy the next day. Fever has continued with the
expulsion at times of verj^ foul material from the
tube. A week later, the child showed less ex-
252
Journal of Iowa State Medical Society
[July, 1922
pansion of the lower right thorax, with var^’ing
degrees of percussion note and loudness of
breath sounds. Does this mean that a small por-
tion of the nut is in the lower right lobe bronchus?
If so, it does not plug it entirely. Or are these
signs due perha])s to secretions which gravitate to
the lowest part and more on the right side ? ( The
subsequent course suggests the latter explana-
tion.)
Chronic Cases — In these the foreign body usu-
ally plugs a lower lobe bronchus. The signs are
usually clear — the bronchus is plugged. Two er-
rors are common, a diagnosis of empyema or tu-
berculosis. Sometimes an abscess or bronchiecta-
sis may be recognized, but the foreign body is
overlooked. The diagnosis of empyema should
be excluded by the area of dullness, the resistance
over which is not that of fluid, the use of the
needle and an x-ray study. As to tuberculosis,
there is no excuse for this error. It is very rare
to have a basal tuberculous lesion without apical
involvement, and a diagnosis of chronic tubercu-
losis without tubercle bacilli in the sputum is to
be looked on with great suspicion. If abscess or
bronchiectasis is recognized, only the thought of
a foreign body as a possible cause may clear the
matter. The error for which there would be
more excuse than any other is thickened pleura
but apparently this is rarely made. The greater
error of diagnosing empyema is the more common
one. There may be some thickening of the pleura
over the affected lobe.
It is evident that the diagnosis must be much
more difficult in the case of foreign bodies
which do not show in the x-ray plate. This em-
phasizes the value of careful study of the signs
in cases which do show, so that the knowledge
gained can be applied to the other group. In
some cases also the signs may suggest the need
of an x-ray plate. One phase of the x-ray study
is of interest as a result of the study of Dr.
Jackson’s patients and I hope that Dr. Manges
will not mind my mentioning it. Dr. Manges can
diagnose the presence and position of a foreign
body which does not show in the x-ray study
about as accurately as one which does. This re-
sulted from a careful study of all cases with es-
pecial attention to the changes in the lung. We
should try to do the same by means of physical
signs. Xo better example of the value of this
can be shown than by the recognition of a small
portion of a foreign body remaining after the
main part has been removed. This occurs, for
example, when several pieces of a nut have been
aspirated. The larger portion or portions may be
removed and a smaller piece remain.
In conclusion, remember the possibility of a
foreign body in ever}- case of doubtful respira-
tory tract diagnosis — and also in what may seem
to be a perfectly clear case. Study the physical
signs carefully over and over again, ^^'atch care-
fully from day to day and remember that rule of
thumb methods are not sufficient — the signs in
each patient must be carefully obser\ed and then
studied. If we remember that the presence of a
foreign body has to be excluded, our mistakes
will be reduced to a minimum.
FRACTURES OF THE LOWER END OF
THE RADIUS*
P. A. Bexdixex, M.D., E.A.C.S., Davenport
In presenting this class of fractures I am deal-
ing with one of the most frequent surgical condi-
tions that the medical practitioner has to treat. I
will not attempt to advance any new ideas relative
to the mechanism of production of the fractures
or to their treatment ; but my aim is to stimulate
renewed interest in this very important class of
fractures.
Codes first described fracture at the lower end
of the radius in 1814, and although he confiused it
somewhat with dislocation of the wrist, which
was supposed to be much more common, his name
has been rightly applied to this injury, since bet-
ter observation on dislocation of new cases has
led to definite knowledge on the subject. The
x-ray has aided materially to our knowledge and
understanding of these fractures, and their char-
acter is well understood from the standpoint of
location and displacement.
That fractures of the lower arm, or base of the
radius, should be of such frequent occurrence one
readily appreciates when the mechanism of pro-
duction is understood. A fall, and the force of
the fall broken by an outstretched arm with the
hand in extension, are the usual conditions from
which it results. In the course of such an acci-
dent, forcible bending back of the hand with over-
extension of the anterior common ligament of the
carpo-radial joint is produced. Strain is brought
to bear on the projecting anterior lip of the lower
end of the radius. The slipping first row of
carpal bones as it moves in the cup-like cavity of
the lower articular surface of the radius fur-
nishes the mechanism through which the force is
transmitted into a cross-breaking strain upon the
bone into which the ligament is inserted, with the
result that that portion of the bone is torn off.
^Presented before the Seventieth Annual Session, Iowa State
Medical Society, Des Moines. Iowa, May 11, 12, 13, 1921.
VoL. XII, Xo. 7|
Journal of Iowa State Medical Soctei y
253
The carpal bones and the meta-carpals are joined
tog^ether with such firmness that but slight motion
is permitted between them. In the movements of
extension and flexion at the wrist, they act prac-
tically as one bone. When the fall occurs, the
bones are locked in this position ; the elbow also
is locked by muscular and ligamentous action,
and we have converted the arm and hand into a
strut, which at the moment striking becomes for
all practical purposes, a column with a small in-
clination to be sure, but very nearly perpen-
dicular, weight above and the resistance below,
and the laws applying to stress in struts and col-
umns apply.
Other anatomical conditions play a part in the
mechanism of these fractures. At the lower ex-
tremity of the radius projects anteriorly a promi-
nent lip, into which is inserted the anterior-radio-
carpal ligaments, the extent of insertion of whose
fibres is continued for a quarter of inch or more,
above the articular margin. This ligament,
though dense and strong, is sufficiently loose to
permit a considerable latitude of motion back-
wards of the carpus upon the radius. The pos-
terior radio-carpal ligament unites the bones to-
gether behind similarly.
Direct J^iolcnce — Fractures of the lower end of
the radius produced by direct violence are com-
paratively rare, except in the variety known as
the chauffeur’s fracture. In the chauffeur’s frac-
ture the mechanism of production is caused by the
sudden forcible back jerk of the crank handle,
puts an unexpected and powerful strain on the
lower end of the radius when the ligament is tense
with the exertion of cranking, causing a trans-
verse or diagonal fracture. (Figure 1.)
The literature up to the present time is still
lacking as to a uniform and rational classification
for fracture of the radius — for example I will
cite two recent authors. Kaufmann divides ra-
dius fractures into the following groups :
1. Radius fracture without dislocation of the place
of fracture.
2. Radius fracture with dislocation of the place of
fracture.
a. Transverse and oblique fractures: 1. Au-
tomobilist fractures. 2. The volar dis-
placement of the peripheral fragments
(so called) Smith-Linhartscher type.
b. Comminuted fractures.
c. The fracture of the ulnar styloid process.
d. The fracture of the ulnar margin of the
radius.
Pilcher in 1917, classified fractures of the
lower end of the radius as follows :
1. Perpendicular wedge-like impact of the carpus
against the articular cup of the base of the radius.
2. Splitting of the lower fragment by descent into
it of the lower end of the upper fragment. Explosive
splitting of lower fragment of radius. P)ackward dis-
placement of lower fragment. Anterior displacement
of the lower fra.gment. Outward displacement of
f Figure 1. Chauffeur’s fracture. Transverse fracture of radius
caused by direct violence.
lower fragment. Epiphysial separation. Dorsal un-
torn periosteum. Incomplete fractures. Fracture of
the ulnar styloid process. .Associated fracture of the
carpal bones. .Associated injuries to the periarticular
structures and diastasis of the ulna.
I will not attempt to make a classification but
I believe that the clas.sification mentioned by
Pilcher is very comprehensive and will serve all
practical purposes.
Force of Impact — In the ordinary accidents,
resulting in a fracture of the base of the radius,
other additional factors to that of avulsion enter.
The most imjiortant of these is the remnant of
the forward and downward impulse of the lower
end of the radius, a force comiiounded by the
weight of the body, and the velocity of the fall
which has been sustained which remains after the
force of avulsion, at first exercised by it is ex-
panded.
Force of Cleavage — It is conceivable that in
the case of a sudden and violent fall, the force of
which is sustained by the hand, the rounded ar-
ticular surface of the carpal mass before the
movement of the backward flexion is completed,
may be driven u]) against the concave articular
surface of the radius with such force as to split
it, or perforate it, and cause the stellate longi-
tudinal lines of fracture in the radial base.
Impacted Fractures — More frequently the
254
Journal of Iowa State Medical Socieia
[July, 1922
lower fragment of the radius is s]>lit into frag-
ments by the descent ; into it is driven the lower
end of the upper fragment or shaft, after the
transverse lesion has been accomiilished. This
impaction of the upjier fragment into the lower
one is generally present when the momentum of
the fall has been great, as in falls from a height.
The extent of the impaction is a fair index of the
force which the elements of the wrist have had to
sustain — the greater the space through which the
fall has had its course, the greater the velocity at-
tained by which the weight of the body is to be
multiplied in producing the resultant force. The
friability of the particular bone involved also is
■* factor that modifies the result in any given
Figure 2. Impacted fracture. Showing the impaction of the
upper fragment into lower fragment.
case. In this class of cases the lower end of the
radius is not only torn off, but as a part of the
train of events if the backward movement of the
lower fragment has not been great enough to
carry it clear off the broken surface of the frag-
ment, it is driven into the lower fragment, and
splits it into secondary fragments, more or less
numerous. ( Figure 2. )
Explosive Splitting of Lozvcr Fragments of
Radius — This form of fracture is comparatively
rare. The usual backward disj)lacement of the
upper fragment has not taken place before the
denser cylinder of the upper fragment has been
driven down into the cancellous tissue of the
lower fragment, with such force that the pieces
into which the lower fragment has been split, arc
driven off in various directions to the palmer as
well as to the dorsal side. In this class of cases
we find a marked shortening of the radius and an
outward ])rotrusion of the head of the ulna.
Backzvard Displacement of the Lozver Frag-
ment of Radius — The usual typical disjdacement
that characterizes the ordinary fracture of the
lower e.xtremitv of the radius is a movement to-
wards the dorsum of the lower fragment. This
is the chief cause of the deformitv which pro-
claims the fracture. It is characterized by the so-
called fork handle deformitv with the line of
Figure Exaggerated backward displacement of the lower
fragment of the radius, dorsal dislocation of the carpal bones,
with a compound dislocation of the ulna.
fracture within three-fourths of an inch of the
lower articular surface of the radius, extending
obliquely downward and forward — thus- permit-
ting the lower fragment to be displaced upward
and backward. This causes the articular surface
of the radius to look slightly dorsalward, and
more towards the thumb and the styloid process
Figure 4. Lateral displacement of the lower fragment.
of the radius to be raised to the level of the ulnar
styloid, or even a little higher, and giving the
hand a position of slight adduction thereby pro-
ducing a distinct prominence of the lower end of
the ulna. ( Figure .5. i
VoL. XII, Xo. 7 1
Journal of Iowa State Medical Society
255
Ouhvard Dis/'lareiiiciit of the Lozver Frayment
■ — The immediate effect of the "iving way of the
radius and backward slii)i)ing of the carpal frag-
ment is a movement of rotation in the direction
of supination of the caqial mass around the head
of the ulna. Not infrequently the strain upon the
carpD-ulnar ligamentous fibres is so great that the
styloid process of the ulna is torn off. The
broken lower end of the shaft of the radius is
Figures 5-A and o-l>. Anterior displacement of the lower
fragment.
thrust forward and the expanded lower articular
fragment is made to appear to have moved lat-
erally. (Figure 4.)
.Interior Displacement of the Lozver Fragmeyit
— In falls upon the wrist with the hand in forward
flexion, it would seem theoretically possible that
the lower end of the radius might be torn off. In
this type of cases we do not get the typical fork
handle deformity, but get a reversed Codes frac-
ture. A typical Codes fracture always results
from volar pressure mechanism; and it never re-
sults from dorsal pressure mechanism. ( Figure
5-a and 5-b. )
Epiphysial Separation — In children and adoles-
cents up to the age when the conjugate epiphysial
cartidage becomes ossified — nineteenth to twen-
tieth year — the result of a cross-breaking strain
upon the lower end of the radius may be that the
fragment that is torn off, is composed practically
of the epiphysis only. Owing to the relatively
small size of the bony nucleus of the epiphysis
during early childhood, the base of the radius
during this period ]>artakes of the tough and
Figure (*. Epiphysial separation — anterior posterior view.
elastic characteristics of the predominating car-
tilage, rather than of the friability and density of
bone. The cases of epiphysial separation re-
corded are practically limited to the years be-
tween twelve to twenty. Fpi])hysial separations
Figures 7-A and T-H. Showing a common location of a frac-
ture in children. Freak above the epiphysial line due to the
elasticity and resiliency of the osseocartilaginous tissue.
are comparativelv infreijuent, because of the elas-
ticity and resiliency of the osteocartilaginous tis-
sue of childh(;od. ( I'igure 6 and Figure 7-a
and 7-b.
Incomplete Fractures — Under this group we
must place fracture of the radius in which the
lower end is but partially torn off. In this same
class belongs the longitudinal sjdits and the ra-
diating fis.sures. Irregular longitudinal fissuring
may be observed without transverse fractures,
with transverse fractures, and with oblique frac-
tures. This variety is rather unusual and is gen-
erally the results of transmitted force directed
upward through the hyperflexed palm and carpal
bones. ( Figure S. i
256
louRNAL OF Iowa State Medical Society
[JcLY, 1922
The association of a fracture of the styloid
process of the ulna is jiroduced by a sheering pro-
cess. The break in the radius lets the ulna down
so that the styloid meets resistance and is sheered
off. (See Figure 4. )
Symptoms — In nearly all cases we have severe
pain about the lower end of the radius and ulna.
Function of the wrist and forearm is impaired.
On pressure over the fractured area, the patient
experiences localized tenderness. Crepitus is a
symptom which is often absent, and it causes pain
Filjure S. Transverse fracture wivh lonjjitiidinal si>lits in lower
(T.d of upper fragment.
to the patient only when demonstrated. Many of
these fractures are impacted and some are com-
minuted, and crepitus is not demonstrable without
undue force.
Swelling is present to a greater or less degree
about the wrist joint. In the classic fracture, the
normal radial arch is gone, and on the extensor
surface, swelling over the upper end of the lower
fragment extending downward for a variable dis-
tance will be found. The lateral view will give
the .so-called fork handle deformity. The hand is
usually abducted, and a broadening of the wrist is
noticeable. Posteriorly, there is a loss of promi-
nence of the styloid process of the ulna with a
corresponding prominence of the same on the
flexor surface of the wrist, bringing it in a closer
relationship with the pisiform bone.
In the non-classic fractures of the lower end of
the radius, the svm])toms abo\e described will be
wholly or in part absent, and when jiresent, may
show specific difference, so each case must be
judged upon its own merits as no two fractures
may give the same train of signs or symptoms.
Di-agnosis — The diagnosis of fracture of the
lower end of the radius is made by a careful in-
sjiection, palpation and court of last appeal, the
x-ray, and resort to it should be made whenever
practicable, to both confirm and correct the diag-
nosis, and later to demonstrate the degree to'
which proper reduction of the fragments has been
obtained.
Differential Diagnosis — To differentiate the
various bone lesions about the wrist joint is very
essential from a therapeutic standpoint, as dis-
placements must be corrected and articular sur-
faces protected. Conditions that may be mis-
taken for the classic fracture are backward and
forward luxation at the radio-carpal articulation,
medio-carjial backward luxation, chipping off at
the posterior edge of the radius at the radio-
carpal joint and qf the anterior edge of the
radius. The x-ray in all of these cases should be
universally employed.
Prognosis — Bony union is almost invariable,
but in many cases too prompt. In neglected cases
after a month, the deformity is marked and it is
very difficult to break up the union. In adults,
with the best reduction possible, some shortening
of the radius or tilting of the lower fragment,
thickening of the wrist and prominence of the
ulnar styloid may be expected. Function is fre-
quently good even with a marked deformity.
Prognosis in most cases depends u])on the man-
ner of reduction and the vital question of after
treatment.
Treatment — Before attempting to treat an in-
jury about the wrist joint, the ))hysician or sur-
geon should have a clear conce])tion as to the ex-
act nature of the fracture. Reduction should not
be attempted until such conception has been ac-
cjuired.
A careful x-rav study should be made of all in-
juries about the wrist joint. 'I'he x-ray tells us
two things which are imjiortant. Are the two
planes of the wrist joint, lateral and anterior
])Osterior. restored so as to aj)proximate normal .'
If the lateral jilane is not restored, it is quite ob-
vious that the entire hand will be thrown towards
the thumb side, abducted, the ulna will be unduly
prominent, and if the anterior jjosterior plane is
not restored, it is equally obvious that a certain
amount of backward di.s]4acement of the hand
will remain and the anterior curve of the wrist
be exaggerated.
A good guide as to whether or not a complete
reduction has been accom])lished is to take the
VoL. XII, No. 7 1
Journal of Iowa State Medical Society
257
x-ray plate (Figure 9) and erect a perpendicular
A-B on the ulna as this bone is rarely fractured.
Draw this line as nearly in the longitudinal center
as possible. Then draw a line through the lower
surface of the ulna, cutting through the enlarge-
ment of the lower end of the radius. B-C is
this line. From B draw a line to the lower inner
side of the radial styloid, B-D. In a great ma-
jority, this angle will be found to be between 14
and 20 degrees. Should there be any great devia-
tion in the plane of the articular surface, it will
show in the reading of this angle. The nearer the
line D-B comes to C-B the greater the change in
Kigure 9. A normal lateral plane. Angle K. 1). usually
heiwecn 14 degrees and 20 degrees.
the lateral plane of the joint, and the smaller the
angle. It is better to be forearmed and to have a
definite idea of what is coming in the way of
permanent deformity than to have a patient dis-
cover this later for himself.
d'here are many methods of retluction which
may be used in reducing fractures of the base of
the radius, but no one method of reduction is ap-
plicable to all cases. The reduction must bring
the displaced and rotated fragment down into
])lace. When it does, the hand will lie laxly in a
position of flexion if the forearm alone is sup-
ported, and the silver fork deformity will have
disaj)])eared.
Anesthetic — In many instances fractures of the
radius can be reduced without an anesthetic but
my experience has been that a better reduction
can be obtained with more comfort to the patient
when a little gas or ether is administered.
Splinting — IMaintenance of reduction may be
accomplished by the use of any of several forms
of dressing. A gypsum s])lint moulded to fit the
dorsal or the flexor surface when the wrist is
somewhat flexed, cannot be improved upon. A
padded narrow wooden splint supplied to the dor-
sal surface of the forearm and hand, extending
from a few inches below the elbow to a point just
above the meta-carpo-phalangeal joints will
steady the fragment. A small pad should, how-
ever, be placed on the palmer side in the concavity
of the base of the radius.
The entire question of splinting resolves itself
into two factors — namely, to retain the reduction
and the preservation of the normal or approx-
imate normal radial arch.
After Treatment — The main point in regard to
the after treatment is early motion. In the more
serious cases, motion is given the joint every day
for ten to fifteen minutes, at first passively, and
on the third or fourth day, active motions are sub-
stituted for passive. Do not jiermit the joints to
stiffen as this can be easily prevented by early
massage and early active and passive motion m
every case.
Operative Treatment — Indications for opera-
tive treatment are limited and personally I have
never seen a case that had to be reduced by an
open operation.
Conclusion
The writer wishes to emphasize the following;
First — No reduction should be attempted until
a careful x-ray examination has been made.
Second — Accurate reduction of the fracture is
of vital importance.
Third — Proper fixation splints should be ap-
plied.
Fourth — Early jiassive and active motion
should be instituted beginning within three days.
Fifth — Early and proper massage.
.Sixth — Remove the splints as soon as possible.
literature and REFERENCES:
1. Ashhurt, A. P. C.; Am. J. Surg., 24, 1913.
2. Burnham: Fracture about the Wrist in Childhood and
Adolescence. Annals of Surgery, 64, 1916, p. 318.
3. Kaufman, C. : Diagii. U. Behandl der subcut. Radiusfrak-
tur am I landgelenke. Deutsche Zeitehr F. Chir., 116. 1912, p. 140.
4. Pilcher: Fractures of the Power Extremity or Base of the
Radius. Annals of Surgery, 65, 1917, p. 1.
5. Xeuhof and Wolf. Surg. Gyneco. and Obst. 20, 1915.
6. Stevens. J. H.: Compression Fractures of the Lower End
of the Radius, .\nnals of Surgery, 71, 1920. p. 594.
7. Roberts and Kelly. Treatise on Fractures, 1916.
8. Speed, Kellogg: Fractures and Dislocations, 15)16.
9. Troell, A.: On Fractures of the Forearm in the Region
of the Wrist. Annals of Surgery, 72, 1920. p. 428.
258
Journal of Iowa State Medical Society
[July, 1922
Discussion
Dr. Alva P. Stoner, Des Moines — From the stand-
point of deformity and in many other respects, es-
pecially impairment of function of the wrist-joint
afterwards, this class of fractures is the most im-
portant of any that we have had to contend with.
In 1912 Dr. J. B. ^Murphy, in a paper read before the
American Medical Association, made the statement
that from 85 to 92 per cent of these fractures resulted
in more or less deformity and impairment of func-
tion. This percentage is perhaps a little high, never-
theless, we find that a very large percentage do result
in disturbance of function. Fracture at the lower
end of the radius is usually caused by a fall upon the
palm of the hand, and is known as Colles’ fracture —
a fracture which results from a force expended in
this direction (indicating). As Dr. Bendixen stated,
if there is any displacement whatsoever, the lower
fragment is invariably rotated backward and out-
ward. Dr. Colies described the fracture over 100
years ago. Lp to that time these fractures were
treated either as sprains, or dislocations of the carpal
bones. .Any other kind of a fracture at the lower
end of the radius is not a Colies fracture. One
point which Dr. Bendixen did not, I believe, call at-
tention to, is that in a strictly Colies fracture, es-
pecially where there is rotation of the lower frag-
ment, almost invariably there is more or less dislo-
cation at the lower end of the ulna; the internal
lateral ligament and the triangular fibrocartilage are
torn, and many times, as the essayist stated, the
styloid process of the ulna is broken off. Now, we
have to treat a dislocation as well as a fracture of
the lower end of the radius. Dr. Bendixen stated
that all of these fractures should be x-rayed. That
is true. Sometimes, however, especially in the coun-
try, one may not have access to the x-ray. Where
fracture exists I have found that there is always more
pain complained of along the line of fracture. This
is simply a diagnostic point which may be of value
where you do not have access to the x-ray. In re-
gard to treatment, I think we owe to the late Dr.
J. B. Murphy as much for his advice as to the best
method of reducing a fracture of the Colles’ type, as
for any other one thing he taught us in relation to
joint injuries. Up to the time of bringing out this
method of handling these cases, the popular method
and about the only method practiced was a straight
pull forward. The proper method of making reduc-
tion has been given in detail by the essayist — hyper-
extension, at the same time pressing the lower frag-
ment into place. These are very difficult fractures
to reduce by any other method. However, usually
they are easily reduced by this method. With ref-
erence to further treatment of these cases, I believe
in early massage. I was well pleased with Dr. Ben-
dixen's idea of early massage. I begin within forty-
eight hours to produce passive motion. Leave the
fingers free and encourage the patient to work his
fingers as soon as he is out from under the anes-
thetic. Never undertake to reduce one of these frac-
tures without giving the patient an anesthetic.
Dr. John E. Brinkman, Waterloo — I believe that
the medical profession is under lasting obligations to
Henry Ford, for he has perhaps furnished us with
more Colles than any other man. There are two
points I wish to make: (1) We sometimes have a
fracture with practically no dislocation, and we con-
tent ourselves with simply splinting the case. I
think .every case of impacted fracture should be first
thoroughly broken up. Do not be content to do up
a fracture simply because the alignment is good, but
break up the fracture. Administer an anesthetic, for
you cannot apply a splint to any fracture without the
patient has an anesthetic. (2) If the fracture is
properly reduced you will not as a rule have much
pain. When I have put up a fracture and the patient
complains of a great deal of pain, I feel that the frac-
ture has not been properly reduced. If proper re-
duction has been effected there will be very little
pain. But be sure that you do not let an impacted
fracture go and satisfy yourself with the simple ap-
plication of a splint.
Dr. J. S. Gaumer, Fairfield — In quoting Dr. Mur-
phy’s teaching as to reduction of a typical Colles
fracture with impaction, it seemed to me that Dr.
Stoner missed an important point in this reduction.
Dr. Alurphy once said that reduction of a Colles
fracture was simple, easy, and uniformly neglected.
He stated that it was necessary first to break up this
impaction, as has been said, and then with the thumb
on the distal fragment to press down upon it. It
seems to me that the most important point is hyper-
flexion of the wrist, which brings the fragments
down into position and keeps them there. Since
carrj-ing out this procedure I know that I have had
very much better results in treating Colles fracture,
and perhaps hyperflexion is the most important
point in this reduction.
Dr. C. J. Rowan, Iowa City — Dr. Bendixen used
one phrase which is of great significance; that one
must individualize each particular case. I was glad
he did not refer to Colles’ fractures as a class, but
because the deformity and the amount of fracture
and the accom])anying injury differ so much in dif-
ferent cases he has stated that each case must be
individualized. That is a very important point. In
fractures of the lower end of the radius we must not
be satisfied with a medium degree of reduction. In
fractures of many bones, especially away from joints,
a reduction may be considered good if we will get
good bony union. In fractures close to the wrist-
joint we must not be satisfied with bony union, but
must secure very accurate reduction if we expect the
function to be good. Therefore the use of the x-ray
before as well as after reduction is very important.
To his test for function, which comprised an anter-
iorposterior view as far as the alignment of the
joint is concerned, I would add a lateral view, be-
cause it is verj' important in these cases that the tilt-
ing of the lower fragment be overcome so that the
natural angle of the joint is preserved.' Dr. Ben-
dixen mentioned the fact that different splints might
\’0L. XII, No. 71
Journal of Iowa State Medical Society
259
be used with success, and I was especially glad to
hear him say except circular casts. In fractures of
this region circular casts have no place. Your diffi-
culty of treatment comes in getting good reduction.
If the fracture is properly reduced and if dressed in
the right position there is not much danger of return
of deformity, therefore a circular cast is not neces-
sary, and might do a great deal of harm. Because
we have a sprain in addition to the fracture there is
a good deal of effusion into the joint, and the circular
cast is likely to cause trouble. I disagree with the
essayist in regard to early passive and active motion
and massage. With proper reduction, with a reten-
tion apparatus that is not producing pressure, it is
well to allow these patients to go for two weeks,
then do away with the splint and allow the patient
to voluntarily begin motion. From the start, with-
out removal of the splint, encourage him to use the
fingers. I have no doubt that Dr. Bendixen’s results
are just as good following early massage and active
and passive motion, but I do not feel that these are
necessary.
Dr. F. R. Holbrook, Des Moines — The mechanics
of this fracture there is not much use in discussing.
There is difference of opinion among observers.
After all, that does not apply so much. The essential
thing is the treatment. An early reduction, as the
essayist has stated, is of paramount importance, and
the next most important point is preservation of
function. All fractures near or into joints have a
double importance because joint function must be
preserved and if it is necessary to sacrifice one or
the other, you had best sacrifice the cosmetic result
for function because a patient who is depending on
his hands, as most of us are, for his living, will get
along much better with a useful joint even if the
arm is slightly deformed, rather than with a good
cosmetic result and loss of function. Simple Colles’
or simple transverse fractures with little or no dis-
placement, once reduced, have a strong tendency to
remain so. Nature has supplied a number of natural
splints in the form of tendons and they have a
tendency to hold the fragments in reduction. Per-
sonally, in some of these cases I have used little,
short, narrow splints about six inches long with
thenar and ulnar cutouts. Of course, the old cast
method passed out years ago and is not used any
more. Also in simple cases splints can be almost
entirely done away with in a very short time. In
some cases I have taken them off in ten or twelve
days, supplying simply a tight wrist strap of adhesive
plaster, allowing the arm to be carried in a sling and
encouraging early motion. The best way to preserve
motion is never to lose it, therefore in Colles’ frac-
ture the joint should be moved right from the start.
Dr. Bendixen — I am glad that so much interest
has been renewed in this very important class of
fractures. As my paper had to be limited I did not
mention the subject of anesthesia. I believ-e that in
every case of reduction, that the reduction should
be made either under gas or ether anesthesia. I am
convinced that the x-ray should be used, and used as
a control, not only to confirm the diagnosis, but to
ascertain the position of the fragments and to de-
termine what their relationship may be after the
fracture has been reduced. Dr. Stoner stated that
many times men living in the country did not have
free access to the x-ray. I rather disagree with him.
I believe that the x-ray is available to almost all
practitioners. With modern transportation, the au-
tomobile, the doctor can readily transport the pa-
tient to one of the larger centers or to the nearest
town where there is an x-ray. It is our duty to the
patient to have an x-ray control so that he may re-
ceive proper treatment for a stiff arm means loss of
function, due to improper treatment and neglect of
taking x-ray pictures. Relative to the method of
treatment favored by Dr. Rowan, that is a personal
matter. What we are after is results. Dr. Rowan
secures good results by his treatment, and I would
not condemn that method because it is the interest
of the patient that you have at heart, and the best
possible results to be obtained are what you want.
I still personally maintain that early massage, active
and passive motion give the best results.
A PRACTICAL DISCUSSION OF MENTAL
STANDARDIZATION*
Frank A. Ely, M.D., Des Moines
There is at present, a tendency on the part of
p.sychologists and psychiatrists to reduce common
sense observations and conclusions concerning the
mental ability of patients, school children, con-
victs and industrial workers, to arithmetical form-
ulas. The statistical and percentage mania has in-
vaded the precincts of our professional activities
in a very formidable manner. It is not the pur-
pose of this paper to ridicule any effort which
may be made to reduce scientific conclusions to a
concrete and workable formula, but to point out
the fact that too close attention to detail, scientifi-
cally as well as otherwise, often blinds one to the
real picture which he is intended to see, and
should see without effort.
Some noted naturalist has said that intensive
concrete observation while in the forest, fre-
quently prevents the observer from noting real
deviations from the normal or from detecting the
camouflage of the denizens of the woods from the
coloring of the forest itself. Intensive deference
to laboratory observation very frequently blinds
us to the obvious clinical phenomena which
should lead the skilled diagnostician to a proper
and easy diagnosis. What has been said relative
to this matter in other channels of observation, is
^Read before the Southwestern Medical Society at Red Oak,
September 22, 1021.
260
Journal of Iowa State Medical Society
[July, 1922
equally if not exceptionally true in the detection
of mental arrestment or inferiority.
Any intelligent observer should be able to pick
out an idiot. The detection of imbecility is al-
most equally easy. The moron presents a little
more difficult problem, and the border-line or
specialized mental defective is even more difficult
to pass upon. The moron or border-line defec-
tive is frecjuently a relativelv normal looking per-
son, possessing in many instances, a superficial
brilliancy and vivacity which is quite deceptive.
Then too, many of these persons, especially the
females, are possessed of attractive physical at-
tributes which appeal to the sentiment of the ob-
server and are apt to throw him off his guard.
The criminalistic border-line defective is by all
odds the greatest medico-legal problem. Under
this classification we have the individual whose
life history is something like this — unstable crim-
inalistic family histopi' which often does not come
to our notice unless we can gain an intimate
knowledge of the family over a period of many
vears, and unless we are able to turn the rusty
lock of the closet door which has long hidden the
family skeleton. As a rule these persons have a
normal birth histor}-, and little if anything oc-
curs to create suspicion up to the age of ten or
twelve, about which time, truancy, lying, mali-
cious teasing, petty thieving, obstinate selfishness,
disregard for property rights, incorrigible diso-
bedience, restlessness and inattentiveness to
studies, call the attention of teachers, neighbors
and juvenile court officers, to the fact that the
individual in question is not cjuite as tractable
and amenable to the rules of conduct which reg-
ulate harmoniously the lives of the rank and file
of his ])laymates. as he should be. Following this,
comes a period during which the offending indi
vidual occasions the teacher and parents a great
deal of perplexity, as a result of which they vacil-
late between the use of moral suasion and cor-
poral punishment — sympathy and exasperation.
After a year or two. during which the delinquent
continues to be a general nuisance and social mis-
fit, the teacher comes to the conclusion that, judg-
ing by the other children, this child is not normal.
The school psychologist is then consulted, with
variable results. If there is a gross mental arrest-
ment it is detected with ease, but if the case be a
“border-liner." technical psvchological tests fre-
cpientlv only serve to confuse the examiner’s
judgment, rather than help it, and it is here that
ordinarv common sense should cast the deciding
vote, either for or against mental normalcy.
"The proof of the pudding is in the eating." If
the child behaves normally it is jirobably normal :
if it behaves in a decidedly abnormal manner, it
is probably abnormal. In making this statement
I may arouse in your minds a certain degree of
antagonism, but I trust you will reserve judgment
until I have made my position more clear. In at-
tempting to standardize anything we are obliged
first, to seek a norm or unit of standardization,
and this starting point or norm, is not an easv
thing to find in a universe filled with individuals,
the jiersonalities of no two of whom are alike.
In a sense, one might say that this is a technical
impossibility. To this objection. I am ready to
accpiiesce, if the norm which is set up is too nar-
row and circumscribed. The native of Alaska
cannot be judged by the same standard used to
judge a Mayflower Bostonian, and in point of
fact you cannot judge a Bostonian or Easterner
in general, by the standards of the Middle West.
Then too, a boy of fifteen cannot be judged by
the .standards set up for the man of age and ex-
jierience. I might go on elaborating upon this
])ha.se of the subject at great length, ’but I will not
do so, since the foregoing hints will adequately
])oint out my meaning. On the other hand vou
will all agree that for a given individual of a
given age. given heredity, given education, given
physical health, and given social restrictions,
there should be social behaviour which is more or
less definitely defined so that even moderate de-
viations from the same may be recognized with
reasonable ease.
W e may say then, that social adaptability is the
sujireme test of mental normalcv. If we stop to
take into consideration the broad subject of indi-
viduality and attempt to represent it graphically,
as we do temperature variations on a hospital
chart, we will note many waves, angles and
curves, but just as a normal person’s temperature
may vary between 97.2 and 98.4 without being
definitely abnormal, so may personality vary one
way or another, and still keep within the bounds
of normal. But if the curve shoots up five de-
grees as the result of hyperaemia of the ego, or
becomes three degrees subnormal as the result of
melancholic perforation of the ego, we should be
able to decide that such variations above or be-
low the normal personality are definitely morbid.
If thirty children all of the same age in a school
room are happih- amenable to the regular rules
of conduct laid down for the pupils of that room,
and one or two in spite of the most intelligent and
kindly efforts of both teacher and parents, fail tt.>
adi>t themselves to the prescribed regime, it cer-
tainly indicates that all things being equal, the two
anti-social children are at least abnormal and in
all probability, subnormal mentally. If five thou-
VoL. XII, Xo. 7 1
Journal of Iowa State Medical Society
261
sand individuals in a jjiven community of mixed
I>opulation, can keep the law and have foresight
enough to understand that the law is made for
them as well as others, and from ten to twenty
are criminalistic, should it not arouse suspicion as
to whether the elements of superior social intelli-
gence are in-esent as a part of their mental equip-
ment.
In dealing with the criminalistic high moron
and border-line mental defective, which classifi-
cations include most of the tramps, paupers, pros-
titutes, and petty criminals, I have observed the
following mental defects, most of whom are to be
looked for in the higher branches of the psychic
tree — in other words, they are within the realm
of the higher specialization of judgment, — viz.:
1. Lack of inhibition, or will power as it is
j)opulaiiy termed.
2. Lack of ability to appreciate a serious fu-
ture calamity wdiich will result from some imme-
diate personal gratification.
3. Lack of appreciation of public interests.
4. Lack of true affection or sentiment.
5. Lack of ability to profit by experience.
6. Lack of foresight in general.
7. Lack of stability.
8. Lack of ability for mental application ancl
prolonged effort.
9. L’ndue amenability to persuasion.
10. L'ndue susceptibility to bad habits.
11. Undue tendency to egotism and autocratic
bombast.
12. Tendency to public bravado w'hile poten-
tially cowardly ; in other words, a tendency to be
a bully.
There are undoubtedly many other character-
istics which I have not mentioned and there are
some that have been mentioned that overlap each
other, but I have simply attempted to paint a
word picture of high grade mental deficiency.
I fancy some one will say there are none of us
who may not manifest some of these defects.
!My reply is, that all of us may have one or more
of such weaknesses to a greater or less degree,
but can you imagine a successful physician w'ho
has no sympathy, wTo has no self-restraint, who
has no foresight, who profits not by experience,
who disregards public welfare, who lacks mental
application, who is autocratic, wTo is egotistic
and a bully? If you can, then I am mistaken. I
know of successful physicians who are egotistic,
and who have a tendency to be bullies, and who
are not always careful of the public w'dfare, but
they have stability, are capable of prolonged ef-
fort, are fairly long on foresight, and possess
other qualifications which spell ability, and which
enable them to fit with a reasonable degree of co-
aptation, into the social structure of their com-
munity. In di.scussing this subject, it might he of
interest to consider the mental status of the re-
ligious, ])olitical and social zealot or fanatic. I
prefer in this connection, to use the term zealot,
as being a non-prejudicial term. A man is very
apt to be a religious zealot as the result of early
environment which included his education, and
even though his \ iews may be at great variance
with those of many of his fellows, they are not
necessarily an indication of mental abnormality,
becau.se he has been trained to think as he doe.^.
He may even believe himself divinely inspired
without being insane or mentally abnormal, if it
is one of the tenets of his faith to believe in mod -
ern inspired prophets. One would scarcely think
the inhabitants of the Amana colonv mentallv de-
fective, because some of them still may have
hopes of a living modern prophet. On the other
hand, if a formerly irreligious jier.son without pre-
vious preparation of an environmental or educa-
tional sort suddenly believes himself to be the
chosen of God, the probabilities are that he has
gone wrong, mentallyi
It is not strange that a man who sprang from
the cotton fields of the sunny south has a leaning
toward the democratic party and still has a sub-
conscious belief in slavery, but the fact that the
solid south swings over to the republican side
when taxes mount too high, is a high tribute to
its faculty of foresight and ability to profit by
experience. Should a man however, adopt a po-
litical party without adequate reason and become
a vociferous exponent of the same, advancing un-
sound and untenable arguments in its behalf, he
then would lay himself liable to suspicion of men-
tal unsoundness. If I, with my environment, ed-
ucation and nativity, should become a bolshevick,
I should certainly expect you to suspicion mv
mental integrity, but for a Russian with no educa-
tion, it is different, because he is only living
up to his environment and Russian traditions.
I think you will all agree with me when I say that
for an Iowa corn bred, corn fed, individual who
has all his life lived in the center of our pros-
perous state — who has to scratch his head to re-
member a year when we ever had a complete crop
failure, and whose eye daily scans a broad horizon
of providential beneficence — to become a loud
mouthed, contentious, bolshevick is presumptive
evidence at least, of mental instability.
So we see that sociability when used in its
broad sense meaning social adaptability, is after
all, the true test of a well developed intellect. Is
it fair to rule out mental arrestm'ent simplv be-
262
Journal of Iowa State Medical Society
[July, 1922
cause an individual can give the sense of a se-
lected reading, tell the difference between a re-
public and a monarchy, tell how a piece of folded
paper will look after it has been cut and unfolded,
or give differences of abstract words.'' During
the war I noticed an article in one of our medical
journals by a Chicago psychologist, who stressed
some solder’s inability to tell what the P. and O.
line meant, as an indication of mental deficiency,
apparently not considering the fact that what he
knew, appealed to him as being a thing that every
one should know.
In our work at the Des iMoines Health Center,
I have been pleased to note a marked tendency on
the part of our psychologist to conservatism in
claims and statements, and this is as it should be.
On the other hand, I have observed a tendency on
my own part and that of many others interested in
the subject of mental standardization, to sidestep
an opinion when we did not have some definite
group of questions or tests to back us up. With
this in mind, I determined to make this phase ot
the subject, the theme of this short paper.
In conclusion I wish to emphasize the following
points :
1. That whatever our technical mental tests
mav be, in the last analysis the conduct of the
individual is of paramount importance, and that
anv conduct at marked variance with the heredity,
environment, and education of the individual,
throws just suspicion on his mental integrity.
2. That a marked and abrupt change in con-
duct speaks for insanity, whereas a life long con-
tinuity of unusual conduct speaks for mental de-
ficiency, either frank or subtle.
3. That social adaptability should be the nat-
ural, normal, mental reaction of an individual, in
direct proportion to the advantages or restrictions
of his environment.
4. That a preponderance of deficiencies in
foresight, inhibition, stability, continuity of ef-
fort, social responsibility, sympathy, and affec-
tion, in a given individual, are just as true and in-
fallible signs of arrested mental development as
are the more tangible signs which may be techni-
callv demonstrated by the 'Simon-Binet tests.
5. That psychologists and psychiatrists should
consider these higher types of mental deficiencies
more seriously and declare themselves with more
decision, even though they are obliged to base
their opinion on the conduct of the individual
rather than upon any series of technical tests.
In other words, psychologically speaking, “The
proof of the pudding is in the eating.”
.SURGICAL INJURIES TO THE BILE
PASSAGES*
A. E. Acker, M.D., Fort Dodge
Not long ago a woman thirty-five years old
who had been under my observation for about
two years \\ ith intermittent gall-bladder attacks
took my advice to have her gall-bladder removed.
The operation was not particularly difficult. Ev-
erything went along nicely for several days when
to my great surprise she began to show evidence
of jaundice which gradually grew more and more
pronounced until she was just about as yellow as
any case of jaundice I had ever seen. The stools
were typically slate colored and the patient’s gen-
eral condition became toxic and depressed. You
can imagine my feeling about this time. But as
time went on it developed that I had not done my
worst but came very near to it. Fortunately I
had put in a drain down to the cystic duct and
had used plain cat gut in my ligations. About
three days after the jaundice was fully developed
bile began to make its appearance at the surface
coming along the line of the drain. This flow of
bile became more and more pronounced until it
appeared that the whole supply of bile was thrown
out on the surface of the body. The jaundice
gradually cleared up but the stools continued clay
colored. I was still very much worried about the
case. But after a time to my great delight the
stools began to change back to normal color, the
flow of bile to the surface of the body diminished
and finally stopped entirely and the patient went
on to a good recover}-.
There is no question in my mind that in ligating
either the cystic duct or some of the bleeding
points I either ligated the common duct entirely
or encroached upon it from the side sufficiently
to shut off its lumen. The drain and absorb-
able suture material ver}- probably saved me
from a very sad and humiliating experience.
This case was a warning to me and is related
first, to emphasize the real purpose of this paper,
which is to sound this warning to you that we
may all approach this line of work with a little
more caution and care in the future.
There is a tendency sometimes, especially after
things have been going well for a considerable
time, to relax just a little, and probably get just a
little too sure of things, until suddenly we are
face to face with the results of an error probably
to the lasting detriment of the patient and to our
great humiliation and embarrassment. I say to
the lasting detriment of the patient because it is a
•Read before the Austin Flint-Cedar Valley Medical Society.
VoL. XII, No. 7 1
Journal of Iowa State Medical Society
263
fact, that the repair of injured bile passages in-
volves some of the most difficult and delicate
surgery known to the profession, and at times
after re])eated attempts, results in final and com-
plete failure. Can you imagine any more de-
plorable condition for anybody than a permanent
biliary fistula. The fact is, however, that these
people usually succumb in the repeated attempt
to restore them to a normal condition. Then
there is another calamity which maA^ happen and
that is the severance of the hepatic artery, which
results in death as has been demonstrated by ex-
periments on animals.
The most important factors in the etiology of
injuries of the bile ducts are;
1. The lack of knowledge on the part of the
majority of surgeons that variations in the mode
of union, course and length of the cystic, hepatic
and common ducts are far more common than our
textbooks on anatomy have led us to believe.
2. The presence of anomalies in the mode of
origins and course of the cystic and hepatic ar-
teries resulting in hemorrhage, and the inclusion
of the bile ducts, either in the grasp of the arteiy
forcejLs, or in a ligature applied around the bleed-
ing point.
3. The obliteration of landmarks as the re-
sult of inflammatory changes.
4. The inadequate exposure of the field of
operation.
5. The closed method of operation.
In considering this subject, it is well to have
in mind the usual relations of the anatomical
structures concerned. Our text-books tell us that
the gall-bladder is on the under surface of the
liver; that it measures from two and one-half
inches to four inches ; that it is pyriform in shape;
that the cystic duct arises at the neck of the gall-
bladder; that it is a tube one and one-half inches
long; that it unites with the hepatic duct at an
acute angle ; that the hepatic duct is two inches
long; that the junction of the two ducts takes
place a distance of about one inch from the intra-
hepatic portion of the hepatic duct ; that the com-
mon duct is about three inches long; that it passes
down between the layers of the lesser omentum
with the hepatic artery to its left and in front of
the portal vein ; that it ])asses behind the first
part of the duodenum, and then between the sec-
ond part of the duodenum and the head of the
pancreas, and ends in the lower part of the second
segment of the duodenum; that the hepatic artery
ascends in the lesser omentum or gastro-hepatic
ligament with the common bile duct and hepatic
bile duct parallel and to the right of it. and with
the portal vein behind it ; that the le-^ser omentum.
bearing these three structures forms the anterior
boundary of the foramen of Whnslow ; that the
cystic artery is a branch of the hepatic ; that it
courses forward and downward and passes pos-
terior to the hepatic duct and through the angle
formed by the hejiatic and cystic ducts; that it
jiasses parallel and along side of the cystic duct.
Now these statements are no doubt true in a ma-
jority of people. But it has been found that theie
are many A^ariations from the typical relations.
The junction of the cystic and hepatic duct may
take place anywhere, from close to the liver down
to the duodenum, and Avhere the junction takes
place low, the cystic and hepatic ducts may run
along parallel and close together.
In this case it would be an easy matter to ligate
and cut off the hepatic duct with the cystic duct.
Only a careful examination and separation of the
two will enable one to avoid this mistake.
The gall-bladder instead of being smooth pyri-
form in shape has been found to vary in form.
The pelvis of the gall-bladder may sag over the
junction of the gall-bladder and cystic duct and
may be found with adhesion to the gastrohepatic
ligament. In this case these adhesions could
easily be mistaken for the cy.stic duct and the
common duct would in this case undoubtedly be
divided. The cystic artery sometimes instead of
running along the side of the cystic duct runs
back of it. It also is shorter than the cystic duct
and as Dr. Wm. Mayo has stated it bears the
same relations to the cystic duct as a bow string
to a bow. When this condition exists the clamp
can easily fail to include the cystic artery Avith the
cystic duct and after the cutting is done it will
begin to bleed. In the hurried attempt to stop
the bleeding the hepatic or common ducts can
easily be injured.
Other variations haA'e been found by Eliott,
Eisendrath and others :
1. The right hepatic artery A'aries greatly in
its relations to the main hepatic and cystic flucts.
2. The variations in the course of the gastro-
duodenal artery and one of its chief branches,
the pancreaticoduodenal, must be borne in mind
in operations on the common duct.
3. The cystic artery does not always arise
from the right hepatic artery just after the latter
crosses the right edge of the main hepatic duct.
4. There is a single cystic artery in only 88
per cent of individuals instead of in 100 per cent
as is generally taught. Even when single, tlie
cystic arter}' does not aKvays arise from the right
hepatic. An overlooked cystic arteiy arising from
gastroduodenal may cause severe bleeding when
accidentally divided.
264
Journal of Iowa State Medical Society
[July, 1922
5. In 12 per cent of individuals there are two
cystic arteries, both of which do not always arise
from the right hepatic. One may arise from the
right hepatic and the other from the main hepatic
or they may botli arise from the left hepatic.
6. Anomalies in the hepatic and common
ducts may be found as variations in the mode of
union of the right and left hepatic ducts before
the main hejiatic duct is formed or as accessor)-
hepatic ducts or finally as a double common duct.
('>r more specifically speaking (a) the cystic duct
may j)ass over the main hepatic duct either an-
teriorly or posteriorly in a spiral manner before
uniting with it. (b) The cystic duct may unite
with the right hepatic duct before the latter unites
with the left hepatic duct. In this case the com-
mon duct is formed by the right and left hepatic,
(c) The cyst duct may unite with the left
hepatic duct to form the common duct in which
case the right hepatic duct empties into the cystic
duct, (d) There may be an accessory hepatic
duct emptying either into the cystic duct or into
the usual hepatic duct or at the junction of the
cy.stic and hejiatic.
The obliteration of normal landmarks by in-
flammatory processes is an important cause of
injuries to the bile pas.sages. We know that gall-
stones are the result of a disease and not strictly
speaking a disea.se within themselves. An infec-
tion always precedes their formation. This is so
true that we seldom speak of gall-stones but pre-
fer to call it gall-bladder disease. This infection
varies from a mild cholecystitis to a violent in-
fection resulting in empyema of the gall-bladder
and extending into the surrounding structures.
After an acute condition like this subsides there
is bound to be extensive adhesions and an ob-
scuring of all the structures involved in an oper-
ation on the gall-bladder and bile ducts. In this
condition the most careful disection must be done
and the greatest caution exercised to prevent
damage to the bile passages.
The inadequate exposure of the field of oper-
ation is another factor of vital imjiortance in this
consideration. The technique as given by Mas-
son I think is about as good as any that can be
followed : “The abdominal incision extends from
the midline at the toji of the ensiform to a point
about two inches external to the umbillicus. If
it is necessary to remove the appendix the inci-
sion may be extended downward, especially if
there is an excessive amount of subcutaneous ti.s-
sLie. When not contraindicated the usual explor-
ation is made. I'he stomach, large bowel, omen-
tum, and small intestine are separated from the
field of operation by three or four abdominal
sponges, held in place by the left hand of an
assistant. It is important when once the sponges
are in place that the assistant should not move
this hand during the operation. In almost ail
such cases this exposure is all that is needed,
even when the right lobe of the liver cannot be
rotated. In the exceptional case, however, addi-
tional exposure is obtained by inserting a pack
(four inches by three feet) between the posterior
superior surface of the right lobe of the liver and
the diaphragm. In this manner the liver is made
to descend slightly, the concave visceral surface
is flattened somewhat, and the hilum of the liver
is made more accessible. The insertion of this
pack is an easy matter and if carefully placed it
can in no way injure either the liver or the dia-
phragm. With an ordinary abdominal retractor
the second assistant retracts the right costal mar-
gin upward and outward, while with a long shoe-
horn retractor the first assistant gently retracts
the liver in the opposite direction. The operator
is now able to place the pack in position by using
a jiair of nine inch tissue forceps, carrying the
gauze along the shoe horn retractor. I have used
this procedure in numerous cholecystectomies,
and am satisfied that it has frequently made very
difficult cases absolutely safe. Injuries to the
hei)atic or common ducts, or hemorrhage, are al-
ways avoidable if the operator can see what he i^'
doing and if he proceeds carefully.”
The fifth factor in the etiology is the closed
method of operation which consists of clamping
and dividing the structures concerned after lo-
cating them through their peritoneal covering.
The open method is achocated by some as a
means of overcoming this obstacle. By this
method the gastrohepatic ligament is made taut
by ])ulling to the left the stomach and intestines
and at the same time pulling to the right on the
gall-bladder and liver. The right free border of
the gastrohepatic ligament is then opened and the
ducts and blood-vessels are exposed to view. The
cystic duct is always separated from its bed be-
fore ligation. The insertion of cystic duct into
the common duct and all other relations are
noted. The variations from normal can be de-
tected by this open method of operating. I realize
there are some operators who take exception to
this open method and there may be cases in
which it may be unnecessary, but the point that I
would like to emphasize is the importance of
definitely locating each structure before a clamp
is applied and any cutting done.
In the large majority of cases the accident is
not discovered at the time of the operation, bin
onlv after the patient has developed a permanent
^ OL. XII, Xo. 7]
Journal of Iowa State Medical Society
265
biliary fistula or jaundice and other symptoms oi
obstruction. In a small minority the obstruction
is the result of cicatricial tissue from gall-stone
ulceration. .Such obstructions are more fre-
auently due to stones impacted in the cystic duct
at the junction of the common duct than to stones
in the common duct itself. The free portion of
the common duct has an extraordinary capacity
for dilatation which is not true of the cystic duct.
Ulceration does occur from stones within the
common duct and leads to the formation of stric-
ture, but usually such strictures have been found
in that portion of the common duct which is fixed
in the head of the pancreas.
Benign tumors of the stump of the cystic duct
mav occur after cholecystectomy and cause ob-
struction of the common duct. Dr. \\ m. Mayo
reported two cases of fibro-adnomata of the re-
maining portion of the cystic duct subsequent to
cholecystectomy. The tumors were nearly the
size of a hazelnut and encapsulated. They cause
typical symptoms of common bile duct obstruc-
tion. The technical phase of this subject will not
be discussed in this paper because the discussion
of the reconstruction of injured biliary passages
is a subject large enough for a paper within itself.
REFERENCES
1. J. C. Masson. Exposure in Gall-Bladder Surgery, Mayo
Clinic. 1919. Vol. xi, p. 1123.
2. Moses Behrend. An Improved Technic for the Removal
of the Gall-Bladder. J. Am. M. Ass’n, 1920, Vol. 75, No. 4,
page 222.
:5. Daniel N. Eisendrath. Operative Injury of the Common
and Hepatic Bile-Ducts, Surg., Gynec. and Obst., 1920. Vol.
xxxi. page 1.
4. \\ m. J. Mayo. Restoration of the Bile Passages After
Serious Injury to the Common or Hepatic Ducts. Surg., Gynec.
and Ohst., January, 1916, page 1.
5. Horatio B. Sweetser. Injury to the Bile Ducts and
Methods of Repair. Annals of Surg., 1921. Vol. Ixxiii No. 5,
page 629.
6. Ellsworth Elliot, Jr. The Repair and Reconstruction of
the Hepatic and Common Bile Ducts. Surg., Gynec. and Obst.,
191S. Vol. xxvi, page 81.
THE SHEPPARD-TOWXER BILL*
Kate Harpel, M.D., Boone
I was requested by your secretary to present
the essentials of the Sheppard-Towner bill ana
any recent legislation affecting the health of
women and children.
The bill known as the Sheppard-Towner bill
was introduced in the senate by Senator Shep-
pard and into the house by Representative
Towner. It is a bill for the public protection ot
maternity and infancy and provides a method of
co-of)eration between the government of the
I’nited States and the several states. It is offi-
■Rea(i before the Seventieth Annual Session, Iowa State Medical
Society. Des Moines, Iowa, May 11, 12, 13, 1921.
cially known as Senate Bill Xo. 3259. Union
Calendar Xo. 416.
This bill was jiassed by the senate December
18, 1920. It was held up in the house committee'
so that it did not come to a vote and now it has
been re-introducetl in both senate and house by
the same men who first introduced it. The orig-
inal bill provided for a maximum appropriation
of $4,000,000 to carry out the provisions of the
bill. This was reduced by a senate amendment to
$1,480,000 and it was reintroduced as amended.
$480,000 is to be dii ided equally among the states
giving $10,000 annually to each state, and the re-
maining $1,000,000 to be given annually, is to be
apportioned among the states in the proportion
which their population bears to the total popula-
tion of the United States. Provided that, no pay-
ment out of the $1,000,000 to be pro-rated among
the states, shall be made to any state until an
equal sum has been appropriated by that state for
that year. So much of the amount apportioned
to any state as remains unexpended at the close
of any year shall be held for that state until the
close of the succeeding fiscal year. At the close
of that time it shall be reapportioned among the
states on the same basis as the original apportion-
ment. '
Sec. 3. The Children’s Bureau of the Depart-
ment of Labor shall be charged with the carry-
ing out of the i)rovisions of this Act, and the
Chief of the Children’s Bureau shall be the execu-
tive officer. The Chief is hereby authorized to
form an advisory committee to consult and ad-
vise concerning any problems which may arise in
connection with the carrying out of the provisions
of this Act, such advisory committee to consist of
the Secretary of Agriculture, the Surgeon-Gen-
eral of the Lk S. Public Health Service, and the
U. S. Commissioner of Education. The Chil-
dren’s Bureau shall have charge of all matters
concerning the administration of this Act, and
shall have power to co-operate with state agencies
authorized to carry out its provisions. It shall
be the duty of the Children’s Bureau to make or
cause to be made such studies, investigations and
reports as will i)romote the efficient administra-
tion of this Act.
In order to secure the benefits of the appropri-
ations authorized in this Act any state shall,
through the legislative authority thereof, accept
the provisions of this Act and designate or auth
orize the creation of a state agency with which
the Children’s Bureau shall have a.ll necessary
power to co-operate in the administration of this
Act; provided. That in any state having a Child
\\’elfare or a Child Hygiene Division of its state
266
Journal of Iowa State Medical Society
[July, 1922
agency of health the state agency of health shall
administer the provisions of this Act througn
such divisions. A state advisory committee may
be selected at least half of which shall be women,
such committee to serve without compensation.
If in any state the legislature does not meet in
1921, the governor of such state shall under the
provisions of this law, accept the provisions of
this Act and create or designate a state agency to
co-o]ierate with the Children’s Bureau. The Chil-
dren’s Bureau shall recognize such state agency
until the state legislature meets and has been in
session sixty days.
Xot to exceed 5 per cent of the amount author-
ized for any year may be used by the Children’s
Bureau for administration purposes. The Chil-
dren’s Bureau is authorized to employ office
force from the eligible list of the civil service
commission and to purchase supplies, office fix-
tures and apparatus and incur traveling expense
as it deems necessary for the carrying out of this
Act.
Any state desiring to avail itself of the benefits
of this Act shall through its agency for carrying
out the Act submit to the Children’s Bureau for
its approval detailed plans for carrying out the
provisions of this Act, and th^se plans are to be
approved by the Children’s Bureau, and notice of
approval sent by the Chief.
In order to jirovide popular non-technical in-
struction on the subject of hygiene of infancy,
hygiene of maternity and related subjects, the
state agency is authorized to arrange with any
educational institution for extension courses by
qualified lecturers, provided not more than 25
]>er cent of the sums granted by the U. S. to a
state can be used for this purpose.
The facilities provided by any state agency co-
operating under the provisions of this Act shall
be available to all the residents of the state.
The Children’s Bureau may withhold the allot-
ment of moneys to any state whenever it shall be
determined that such moneys are not being ex-
pended for the purpose and under the conditions
of this Act. The state may appeal to the Secre-
tarv of Labor. His decision shall be final.
Xo portion of moneys apportioned under this
Act for the benefit of states, shall be applied di-
rectly or indirectly for the purchase, equipment
or rental of buildings.
It was shown in the hearings of this bill that in
a single s'ear 23.000 mothers died in childbirth,
and nearly 250,000 infants died under one year of
age, and that most of these deaths are prevent-
able. Maternal mortality and infant mortality
from maternal causes are not decreasing in the
U. S. During the past twenty years the typhoid
rate has been reduced more than 50 per cent, the
tuberculosis rate has been remarkably reduced,
the diphtheria rate has been reduced more than
one-half, but there has been no decrease in ma-
ternal deaths, principally because mothers do not
have the necessary care, advice, and assistance
they need. Other countries show lower death
rates from these causes than our own. It is
stated that it is safer to be a mother in seventeen
important foreign countries than in the United
States, and that babies have a better chance in
ten foreign countries than in our own. Probably
the most discouraging feature of the situation lies
in the fact that no progress is being made. In this
enlightened age and in this prosperous country
more women between the ages of fifteen and
forty-five lose their lives from conditions con-
nected with childbirth than from any other cause
except tuberculosis.
The actuary of one of the largest insurance
companies from his investigations reports that
deaths from maternal causes actually increased
in the United States in the year 1920 over the
year 1919 15 per cent. It is practically certain
that 25,000 mothers will lose their lives from
causes arising out of motherhood this year al-
though we know that at least half of these could
be saved by advice, care, and timely help. In a
tenement portion of X"ew York City where work
has been carried on by a nurses’ association sup-
ported by private contributions 4,683 cases were
cared for. X’^ot one mother died, and only one
infant for each 102 born. The city death rate
for all, per 1,000 cases of all infants under one
month was 37. It will thus be seen that the work
done by these nurses reduced the death rate of
these infants from 37 to 10 per 1,000. Miss
Baker, director of child hygiene, Xew York, say.s,
thev ha\ e pivn ed o\er and over again that with
instruction and help the death rate of women who
die of maternal causes can be reduced one-half
to two-thirds. An insurance statistical! report
that when attention and care in prenatal and ma-
ternity cases are given under skilled direction
onlv two women instead of five per 1,000 die.
Only ten infants instead of forty die under one
month of age per 1,000. It seems to be pro\en
beyond a doubt that we can, merely by enlarging
the activities of the state, bring to bear upon
these terrible conditions such service as will an-
nually save the lives of thousands of mothers and
tens of thousands of children.
I know of no recent national legislation dealing
with the health of women or children.
Lmder Iowa legislation, you probably all know
You XII, Xo. 7J
• Journal of Iowa State Medical Society
267
that the last session of our state legislature passed
a vital statistics bill which admits us to the na-
tional registration area. This system of birth
registration will furnish knowledge upon which
much health work can be based and in many
ways will be of value to the children.
The last legislature also passed a bill requiring
universal compulsoiy- treatment of the eyes of
the new-born, to prevent infection unless the par-
ents were religiously opposed. This last was a
concession to the Christian Scientists.
They amended our cigarette law in the interests
of enforcement. The original law made the keep-
ing of cigarettes for sale to any one illegal. Many
people felt this to be an infringement of personal
liberty. After July 4 they can be kept for sale by
those having a license to sell, and be sold to per-
sons over twenty-one years of age. If the sale to
minors can be stopped it will mean much to the
health of the children.
The age of consent for girls was raised from
fifteen to sixteen, and to seventeen if the man in
the case was over twenty- five years of age.
Under recent legislation affecting health I feel
that I should mention our venereal law, passed
two years ago, for the enforcement of which our
last legislature appropriated $25,000 annually.
The Perkins law is not so recent, having been in
0{)eration for six years. It is however doing
great good among the children of the state.
The appropriations made by the last legislature
for tuberculosis work are worthy of mention.
Appropriations were made for additional build-
ings at Oakdale, including one for children. Also
for a hospital for the tubercular at Clarinda and
one at Independence. They also increased the
maintenance fund for Oakdale from $50 to $65
per month. They increased the fund for bovine
tuberculosis from $100,000 to $250,000 per an-
num, and the Federal government will spend prac-
tically the same amount in Iowa.
iNIore authority was also given cities to regulate
their milk supply.
KENTUCKY PHYSICIANS OPPOSE SHORTER
MEDICAL COURSE
Delegates of the Kentucky State Medical Society,
in joint session with the health and sanitary commit-
tees of the House and Senate, on January 21, 1922,
opposed a legislative measure designed to relieve a
shortage of physicians in rural districts by reducing
the standard of medical training. The meeting was
called at the request of the governor for the purpose
of drafting a bill which would encourage the training
of more physicians so as to aid the rural districts of
the state. — ^ledical Record.
PHYSICLVXS WHO LOC.VTFD IX IOWA
IX THI-: PFRIOU P.KTWEEX 1850
AND 1860
D. S. Fairchild, M.D., F..\.C.S., Clinton
Dr. Charles Chunn Warden
Dr. Charles Chunn Warden was born Novem-
ber 20, 1816, ^laysville, IMason county, Kentucky.
Died February 14, PX)2, Ottumwa, W'apello
county, Iowa.
Oldest child in the family of Richard Henry
Warden and Elizabeth Charity Chunn, who were
natives of Virginia.
About 1834 the family followed the beaten
track into Ohio. On the death of his father,
Charles, whose education had been obtained in
the common schools of Kentucky and Ohio, sup-
plemented by attendance at an academy in
DR. CHARLES CHUNK WARDEN
(jreensburg, Indiana, engaged in the drug trade
in the last mentioned place. He soon commenced
the study of medicine with Dr. Fogg as his in-
structor. He continued his studies for two years
and then entered the Ohio Medical College at
Cincinnati after which he entered a partnership
with Dr. Fogg, which was terminated by the death
of his partner six months later.
In the spring of 1843 his broken health induced
him to take a trip W'est and he arrived in W'apello
county on July 3, 1843.
W'hen it became known that he was a physi-
cian, he was called on to prescribe and his in-
creasing practice induced him to become a per-
268
Journal of Iowa State Medical Society •
manent resident and was the first physician to lo-
cate in Wapello county.
Dr. Warden followed the active practice of
medicine for thirteen years and after that time
engaged in the drygoods business. Much of his
time was devoted to educational interests and for
twehe years he was president of the board of
education in the ])ublic schools of Ottumwa, and
for four years was a member of the board of
trustees of the agricultural college at Ames, two
years of that time acting as chairman.
Doctor Warden belonged to the type of pioneer
which has built the State of Iowa — bringing to
the frontier the integrity and sagacity which bind
together the best in the struggling settlements and
cementing the foundations of our commonwealth,
and his philosophic acceptance of the unrecorded
hardships of sickness and debt and exposure was
an inspiration to his neighbors. The mute re-
minders of his earh' struggles, his shabby saddle
bags, his rusty surgical instruments, his mortar
and pestle, his matriculation cards to the Ohio
Medical College are still treasured by the sur-
viving members of his family who reside in Ot-
tumwa. His name is to be found on the rolls of
the Iowa State IMedical Society, 1858, and the
Wapello County Society of which last he served
his term as president.
To him arid others who have seen the wilder-
ness fade away and cities spring up, the present
generation owes a great debt.
It was the Editor’s privilege to be connected
with the State College at Ames when Dr. Warden
was a member of the board of trustees and has a
clear recollection of the usefulness of his services
to the institution, particularly in relation to the
health and welfare of the students. At that time
public health matters, received but little consid-
eration. There was no state board of health
then, and no precautions were taken to prevent
the spread of infectious diseases. All the stu-
dents at the state college were lodged in one great
building, and as college physician, we bad great
difficulty in controlling the spread of infectious
diseases, as measles, scarlet fever, and diphtheria.
Through the influence of Dr. A\’arden the college
physician was made health officer and endowed
with all the authority the law would permit ;
which was little enough you may be sure. This
action of Dr. Warden was con finned by Dr.
\V. S. Robertson, when the state board of health
was formed, who was the first president of the
board, and made the college physician health of-
ficer of the college under state authority.
We are indebted to the courtesy of Mrs. D. C.
[July, 1922
Brockman of Ottumwa for most of the data re-
lating to her father Dr. C. C. Warden.
Dr. Jefferson Williamson
Dr. Jefferson Mhlliamson was born in Adams
county, Ohio, IMarch 31, 1827. Graduated in
medicine in 1852 from the medical department
Western Reserve University. Came to Ottumwa
and entered upon the practice of medicine in No-
vember, 1852, where he practiced continuously
fifty-one years. He died in Ottumwa Januarv
12. 1904 at the age of nearly seventy-seven years.
Dr. W'illiamson was a polished gentleman hold-
ing to high civic and professional standards. Pro-
gressive in his views of medicine, he became rec-
ognized as an ideal family physician. Although
he made no special claims as a surgeon he had
the courage in 1881 to perform an operation for
a large ovarian tumor with a successful result ; at
a time when the operation was looked upon as a
doubtful undertaking.
Dr. Wrilliamson was a constant attendant of
the meetings of the State Medical Society and
was an inspiration to the younger members. He
was active in the business of the society and his
usefulness caused his name to appear at one time
or another on the most important committees
throughout his long membership of forty-five
years. In 1872 he was elected president of the
Society.
The profession of Ottumwa has been partic-
ularly distinguished for its loyalty to high ideals
to which the influence of Dr. Williamson was an
important factor.
Dk. .Seneca Brown Thrall
Dr. .Seneca Brown Thrall was born in Utica,
Licking county, (9hio, .\ugust 9, 1832. Flis
father. Dr. H. L. Thrall was for many years a
])rofes.sor in Kenyon College, and in Starling
Medical College, Columbus, Ohio. Dr. Seneca B.
Thrall graduated A.B. at Kenyon College, re-
ceived his A.M. degree in 1855, and graduated Iti
medicine from the University of New York,
1853. As was the custom at that time, he read
medicine in his preceptor’s office (his father).
Dr. Thrall received a liberal education both in
arts and medicine, as it was thought in those
days, and was well fitted for a career of useful-
ness. His energy and active habits of life brought
unusual success. He commenced practice with
his father and after two years, with his father
and one additional year of practice at Belle Cen-
ter, Logan county, Ohio, he located in Ottumwa
in May, 1856.
In 1859, Dr. Thrall became a member of the
VoL. XII, Xo. 7|
Journal of Iowa State Medical Society
269
Iowa State Aledical Societj’^ and in 1869 was
president. In 1873, he was elected secretar}- of
^he Society in which office he served Until 1877
m a most efficient manner. For nearly thirty
years, Dr. Thrall was one of the most active
members, watchful and uncompromising in his
opposition to medical politics which had for its
purpose the advancement of selfish ambition. For
many years two medical schools factions strug-
gled for supremacy in the councils of the so-
ciety, leading to much ill-feeling, but Drs. Thrall.
Williamson, ^^’atson and others were always-on
guard. The year Dr. Thrall came to Ottumwa
he married Miss Mary Brooks and together they
builded a home where he died January 20, 1888,
fifty-six years of age.
In 1862, Dr. Thrall was appointed a surgeon to
the Keokuk ]\lilitary Hospital, and was soon com-
missioned surgeon to the Thirteenth Iowa In-
fantrv and continued in the service until MaA,
1864.'
Dk. Joseph Crawford Hinsey
Dr. J. C. Hinsey was born in Butter county,
Ohio, June 9, 1829 and died in Ottumwa, April
10, 1892. Graduated from Rush Medical College
in 1851 and from the University of Pennsylvania
in 1854. 1-ocated in Ottumwa in 1856.
In 1862 Governor Kirkwood appointed him
surgeon to the enrollment board for the fourth
congressional district and he served during the
war.
Dr. Hinsey became a member of the State
Medical Society in 1859 and was president in
1887. Dr. Hinsey was one of the few surgeons
in Iowa to perform an ovariotomy in pre-antisep-
tic and pre-aseptic days. The writer recalls the
interest manifested in the days before 1880 at the
presentation of these wonderful operations.
RADIOTHERAPY IN CERTAIN FORMS OF
UTERINE FIBROMA
La I’resse Medical abstracts from the proceedings
of the Surgical Society of Lyons observations made
by M. Condamin on the use of radium in the treat-
ment of uterine fibroids to the effect that it has less
influence than on cancer of the uterus.
In fibromas it arrests the hemorrhage and often
has an appreciable effect in reducing the volume of
the tumor. The use of radium is advised in cases in
which the patient is greatly e.xhausted from hemor-
rhage, until the condition is improveil to permit of a
safe operation.
The technic employed by M. Condamin consists in
a full dilitation of the cervix to admit a metalic stem
protected by caoutchouc and introducing two tubes
of .sO to 60 milligrams which are left in place 36 to 48
hours. It is probable that the arrest of hemorrhage
is due to the hardening of the mucus membrane.
INTERNATIONAL SOCIETY OF MEDICINE
It is announced that an international society has
been established in Paris for the study of the history
of medicine. The officers are Dr. Tricot Royer of
Anvers, president; ITofessors Giordano of Venice,
Singer of Oxford and Jeanselme and iMenetrier of
Paris, vice-presidents, and Professor Laignel-Lavas-
tine of Paris, secretary-general. A convention will
be held at London in July, 1922, when these subjects
will be taken up; The Principle Localities of Epi-
demic and Endemic Diseases in the Middle Ages, in
the Occident and the Orient, and the History of An-
atomy. Professor Singer will act as chairman. — New
York Medical Journal.
RENAL TUBERCULOSIS
Dr. John R. Caulk of St. Louis in a paper before
the St. Louis Medical Society and published in the
Journal of L^rologj'^ draws our attention to some im-
portant and interesting facts in relation to Renal
Tuberculosis. It is stated that 30 per cent of all sui-
gical diseases of the kidney are tuberculous. An im -
portant observation is made that “there has never
been in the history of medical literature a single au-
thentic case of spontaneous healing of a tuberculosis
kidney. The ultimate outcome is always one of com-
plete destruction to the kidney and usually severe
mutilation to the rest of the urinary tract. So we are
faced with the inevitable, and I warn against any
hope for medical cure of renal tuberculosis and urge
early nephrectomy, in order that the deleterious ef-
fects, which it is bound to produce and which I will
describe later, may be prevented.”
Considering chronic or surgical tuberculosis the
author states: “This disease is usually a unilateral
affair, primary in the kidney, as far as the urinary
tract is concerned, but usually secondary to some
other focus in the body such as the lung, bone, gland,
bowel or genital tract. Kuster states that 10 per cent
of patients dying of tuberculosis, have kidney in-
volvement. In 8.3,000 operations at the ^layo Clinic
0.6 per cent were for renal tuberculosis. Kapsamer
in 20,000 autopsies, found 191 cases of renal tubercu-
losis or little less than 1 per cent; of these 191 cases,
67 were unilateral and 124 bilateral. Of the bilateral
cases, his findings indicated that a great majority
showed old processes in one kidney and early in the
other, illustrating that there had been unilateral in-
volvement. but time had allowed the other kidney to
become infected. Halle and ^lotz in 111 cases found
89 unilateral.”
Referring to complications; “The presence of a
true stone, not a lime salt infiltration, in a tuber-
culous kidney is extraordinarily rare, and its re-
moval, so far as can be determined, has been re-
ported but once by Fowler of Washington.”
270
Journal of Iowa State Medical Society
[July, 1922
Jfournal of tije
3otda ^tatc jWcbital ^ociet|>
D. S. Fairchild, Editor .‘.Clinton, Iowa
Publication Committee
D. S. Fairchild Clinton, Iowa
W. L. Bierring Des Moines, Iowa
C. P. Howard Iowa City, Iowa
Trustees
.T. W. CoKENOWER Des Moines, Iowa
T. E. Powers Clarinda, Iowa
\V. B. Small Waterloo, Iowa
SUBSCRIPTION $2.75 PER YEAR
Books for review and society notes, to Dr. D. S.
Fairchild, Clinton. All applications and contracts
for advertising to Dr. T. B. Throckmorton, Des
Moines.
Office of Publication, Des Moines, Iowa
Vol. XII July 15, 1922 No. 7
ST. LOUIS MEETING OF THE AMERICAN
MEDICAL ASSOCIATION
The session of the Xational Association at St.
Louis may be said to have been as successful as
any of the preceding sessions. The Association
has become so large that it is quite impossible for
one person to measure more than a part of it ;
only the part he is personally interested in, or if
his interests are general, by a study of the pro-
gram that he may select from the sections such
men and papers he would like to see or listen to.
The finding of auditorium rooms to care for
some fifteen sections in close proximity is a dif-
ficult matter in most cities. This will be obviated
in San Francisco as the municipal building wdl
accommodate all the sections under one roof.
Onh' the general meeting, will probably seek a
larger auditorium. At this gathering only the
young and vigorous will find it interesting. The
registration for the first three days was 4,853 of
which Iowa contributed 149 and Kansas 205.
It is said, as a measure of reproach, that doc-
tors find it difficult to agree and that contro-
versv is a natural condition of the medical mind.
Being of an inquiring turn of mind and of some
experience at medical conventions we occupied
ourselves to some extent in listening to groups of
men in the hotel lobbies and in conversations with
men who seemed to be in a satisfied state of mind
and with others who appeared to believe that
something was wrong and that they were dele-
gated to watch for evil designs and to remedy any
departure from the “American Idea,” but we
failed to discover anything we were not familiar
with for the forty-eight years of our membership.
Of course it has not always been the same danger
but of the same general character.
The strange and mysterious systems of medi-
cine have always endeavored to fill the mind of
the people with the idea that their methods were
certain and above controversy while “the old
schools” were uncertain, selfish, crude and full
of controversy, and point as evidence of their con-
tention to the pett)- disputes that are said to grow
out of selfishness and uncertainty. It is not
strange that many laymen listen to these claims
and wonder why a true scientific profession of
medicine should present the anomaly of the fore-
most men in the profession, as it appears to them,
fighting over non-essentials. It must seem
strange to a layman that the trusted delegates of
fifteen scientific sections should not represent
their respective sections by seats in the House of
Delegates and vote. It must seem more strange
that men who have grown up from small begin-
nings to positions of leaders, should be so dis-
trusted that they should be turned back into ob-
scurity. The layman would naturally ask if there
was any constitutional provision which prevented
new leaders by diligence and ability to work their
way to the front. But it is a natural instinct of
mankind from savage races to “autocratic Eu-
rope,” to the glorious Republic of America, to
strive for leadership by one method or another.
As society becomes more complex the difficulty
of reaching leadership increases. The desire for
leadership is commendable and should be encour-
aged, not altogether for the individuals’ personal
advantage but in a measure at least for the good
of the ruled. It must be said of the American
Medical Association that it has done remarkably
well in advancing the cause of scientific medicine.
The election of Dr. Wilbur as president-elect i.'
a recognition of high merit. Dr. Wilbur was
born in Boonsboro, Iowa, in 1875 and has grown
from a medical student to be president of Leland
Stanford University, passing through many
grades of service to the high position he now
holds. We of the ^Mississippi Valley had our eye
set on Dr. Jabez N. Jackson of Kansas. City who
had risen to a high position in his profession and
who will not be forgotten at some future election.
INTRACARDIAC INJECTION OF ADRENALIN
IN HEART ARREST
An editorial appears in La Presse IMedicale for
October 22, 1921, on the use of adrenaline ad-
VoL. XII, Xo. 7]
Journal of Iowa State Medical Society
271
ministered by intracardiac injection in sudden ar-
rest of the heart in shock or chloroform anes-
thesia. A few years ago, several papers appeared
in Revue de Chirurgie by Lenorment advocating
exposure and manipulating the heart in cases of
apparent death from anesthesia, chiefly chloro-
form anesthesia. Some twenty-four cases were
given with a considerable proportion of recover-
ies, most of the cases were from French sources.
There were a few American cases among them,
one by W. \V. Keen and one by Dr. W. S. Con-
kling of Des Moines. As this method involved
in some cases the opening the abdomen or thorax,
it never became popular. N^ow we have a more
simple method of stimulating the heart as pointed
out in this editorial review. It is stated that J.
Winter in 1905 communicated to the Medical So-
ciety of Vienne the results of experimental re-
searches with adrenaline on animals in which the
circulation and respiration were suspended by the
inhalation of chloroform, that the injection of
adrenaline into the left ventricle of the heart re-
stored its action when all other methods failed.
Winter contended that in conjunction with arti-
ficial respiration the injection of adrenaline into
the left ventricle through the thoracic walls would
be equally successful. Five years later, Latzke
reported to the same society three cases in which
this treatment was employed. But only under the
influence of the war was this treatment added to
the classical means of the “reanimation” of the
heart. Within the past year E. Vogt, private do-
cent of the Faculty of Medicine of Tubingen col-
lected fifteen cases giving durable results, four
cases by Volkman, three cases by Von den Velden,
two cases by de Walker and six cases by Rue-
diger, Zants, Heydloff, Foster and A. Mayer to
which may be added one case by H. Guthmann of
Erlangen. The writer states that there were fail-
ures which were not reported. There were many
cases in which the condition was such that no
permanent improvement was possible, and it
would appear that the intracardiac injection has-
tened the arrest of the heart in hopeless cases.
The most favorable results were in sudden pro-
found shock and in chloroform narcosis.
The writer, L. Chemisse, discusses the views of
the German contributors as to the merits of in-
trapericardiac, intramyocardiac and intracardiac,
the latter being the most efficient. The technic
is very simple. After disinfecting the skin with
iodine introduced a fine needle (2m.m.) 10 c.m.
in length in the fourth left intercostal space, one
or two fingers breadth from the left sternal bor-
der slightly inclining the needle toward the Me-
dian line. At a depth of from 3j/^ to 4j4 c.m.
resistance ceases and by withdrawing the piston
blood follows, one knows he is in the ventricle.
Inject 1 c.m.- — 1 to 1000 solution adrenalin.
Colorado medicine informs us that a referen-
dum vote is to be taken in Colorado in November
next entitled; “An Act to Prohibit Injurious,
Dangerous or Painful Experimental Operations
or Administrations Upon Human Beings or
Dumb Animals Except to Relieve or Cure Them ;
Making Exceptions of Persons Consenting to
■Such Experiments and Providing Penalties for
Violations of the Act.”
This propaganda is of course under the au-
spices of the Colorado Anti-Vivisection Society
in the interests of Drugless Healers, including
Christian Scientists, Chiropractors, Osteopaths,
and the like and for the purpose of arresting
scientific medicine.
The arguments and statements take us back
to the dark ages and are unworthy of any civilized
or enlightened people. A few of the statements
will show the low intellectual condition reached
by certain people in this nation of boasted intelli-
gence. An article by Eugene Christian, president
of the National Association of Drugless Practi-
tioners, is entitled: “Shall We Let the Doctors
Enslave Us.^” The article is a vilification of the
“Drug Doctors.” The other pamphlets of the
New York Society are equally amazing, for many
of them have no reference to vivisection. Here-
with a few of the titles: “Complete Failure of
Medicine in the World War,” “Dangers in the
Use of Vaccines and Serums,” “The Folly and
Failure of Serums and Vaccines,” “The Utter
Failure of the Old School Serum-Vaccine Method
Versus the Glorious Record of Drugless Doctors
in the Influenza Epidemic,” “What Would Have
Happened Without Osteopathy?”, “What Would
Have Happened Without Chiropractic?”
Abolition of Vivisection issues a pamphlet en-
titled “Black Art Vivisection,” and this pam-
phlet treats of the following topics : “Japanese
Vivisects Four Hundred Charity Patients in New
York,” “Kill Girl at Free Clinic,” “Poor Chil-
dren Blindness by Vivisector,” “Human Beings
Must be Vivisected,” etc.
A referendum vote was taken in California on
the same matter about two years ago and was de-
feated by a large vote. We trust that the same
fate will follow the election in Colorado.
272
Journal of Iowa State Medical Society
[July, 1922
IOWA STATE UNIVERSITY NEWS NOTES
Don M. Griswold, M.D., Iowa City
Through the kindness of certain organizations,
and the efforts, especially, of ^Irs. Stephen Wilder
of Cedar Rapids, a subscription of $1000, has been
raised to be used for the purchasing of play ground
equipment to be employed for the crippled children
at the Perkins Hospital especially during the coming
summer months. A great amount of play ground
equipment has been purchased and there is more to
arrive. Seesaw, merry-go-rounds, etc., will consti-
tute some of this equipment. Two or three tent
covers have been purchased to protect and shield the
children from the hot rays of the sun. A local con-
tractor of Iowa City has donated a large sand table
and more such features are expected to be added
from time to time. It is hoped that the great amount
of time that must necessarily be spent by the chil-
dren in the hospital, will be spent in the open air
and sunshine, and thereby aid the scientific treat-
ment that they receive. Needless to say there is
great appreciation of !Mrs. Wilder's efforts and that
of her friends and it is hoped that this useful work
will be kept up by those of public interest.
Dr. McDonald, director of student health at the
State University of Iowa, spent the 14th and 15th
of May in visiting and observing the conditions at
the student health department at Ann Arbor, Mich-
igan.
Dr. M. O’Harrow of the student health depart-
ment, State University of Iowa, attended the meet-
ing of the Iowa State Society of Medical Women of
Des Moines, May 9th, and presented a paper on
“Health Examination of School Children.’’
The offices of the student health department of the
State University of Iowa, have been enlarged, reno-
vated, newly painted, and new equipment put in, to
accommodate the large number of students expected
the coming year.
Internships for graduating medical students of the
University have been awarded. In Dean Lee Wal-
lace Dean’s department, men who have already
served a year’s internship were appointed as is cus-
tomary.
The awards follow. The department of internal
medicine here, under Dr. C. P. Howard: Glenn W.
Adams of Iowa City, John C. Shrader of Iowa City,
Ernest F. Wahl of Wellman, and Daniel V. Conwell
of Iowa City. Department of surgery, here; John J.
Collins of Williamsburg, Lawrence A. Block of Dav-
enport, Paul N. Mutschmann of Bellevue, and Harold
G. King of Boise, Idaho. Mary A. Rose of Rockwell
City enters the department as an anesthetist.
Department of pediatrics here: Morgan J, Foster
of Wellman, Arnold Smythe of Scranton, and Oral
L. Thorburn of Webster. Department of ortho-
pedics: George L. Dixon of Burlington and Fred W.
Hark of Dysart. Department of gynecology and ob-
stetrics; Frank G. Valiquette of Sioux City and
Glenn N. Rotton of Essex.
To Jennie Edmundson Hospital of Council Bluffs:
H. F. Johnson of Iowa City and Glenn R. Cutter of
Cedar Rapids. To Methodist Hospital^ Des Moines;
Wendell B. Sperow of Carlisle, Thomas B. Murphy
of Des Moines, Alfred R. Lekwa of Dows, and Will-
iam B. Dixon of Mount A’ernon. To Harper Hos-
pital, Detroit; Alfred P. Synhorst of Pella, Martin
H. Hoffman of Dubuque, and Lewis L. Leighton of
Iowa City. To Receiving Hospital, Detroit: James
H. Wise of Cherokee and Arthur L. Jones of Sioux
City. To Lakeside Hospital, Cleveland: Simon A.
Schluster of Fort Madison, Ivan F. Weidlein of
Wellman, and Herbert Boysen of Sioux City.
To Children’s Hospital, San Francisco: Ina Gour-
ley of Ottumwa. To Methodist Hospital, Omaha:
Chester J. Sturges of Buffalo, Minnesota. To North
Side Hospital, Chicago; Edwin J. Smith of Iowa
City. To Charity Hospital, Cleveland: Robert N.
Larimer of Iowa City.
To Doctor Dean’s department go Horace Hosford
of Burlington, Dean Lierly of Marshalltown, and
W. A. McNichols of Osceola, Benjamin Synhorst of
Pella goes to the Mayo Clinic, Rochester, Minnesota.
Other students graduating in medicine who have
not as yet decided where to take their internships
are: Florence E. White of West Branch, Clarence
P. Phillips of Mason City, and Henry B. Hibbe of
Dubuque.
PUBLIC HEALTH CONFERENCE
The State University of Iowa, College of Medicine,
Extension Division, and State Board of Health
Cooperating
Iowa City, July 18, 19, 20, 21, 1922
PROGRAM
Tuesday, July 18
10:00 A. ^I. Address of Welcome, Walter A.
Jessup, President, University of Iowa.
10:30 A. M. Response — Dr. D. C. Steelsmith, Di-
rector, County and City Health Department, Du-
buque.
11:00 A. ^I. Diphtheria Prevention — Dr. Don M.
Griswold, State Epidemiologist and Director of the
State Board of Health Laboratories.
2:00 P. M. County Health Work — Dr. D. C. Steel-
smith.
3:00 P. M. Responsibility of the Health Officer
in Protecting the Public Water Supply — Jack J. Hin-
man, Jr., Chief of the Water Laboratory State Board
of Health.
4:00 P. M. Inspection of Water Laboratory and
Sanitary Exhibits.
VoL. XII, Xo. 7]
Journal of Iowa State Medical Society
273
Wednesday, July 19
9:00 A. M. The Student Health Service of the
State University — Dr. C. R. Thomas, Assistant Di-
rector, University Health Service.
10:00 A. M. The Control of Communicable Dis-
eases in Schools — Dr. Don M. Griswold.
11:00 -A. M. Municipal Health Protection — Dr. E.
Marsh Williams, City Health Officer, Oskaloosa.
2:00 P. M. The Health Center— Dr. Reul H. Syl-
vester, Director, Des Moines Health Center.
3:00 P. M. Mental Health — Dr. Lawson G.
Lowery, Assistant Director, Psychopathic Hospital.
4:00 P. M. Inspection of Children’s and Psycho-
pathic Hospitals.
Thursday, July 20
9:00 A. M. The State Board of Health and the
Local Health Officer — Dr. Rodney P. Fagan, Secre-
tary, State Board of Health.
10:00 A. M. The State Venereal Disease Program
— Dr. W. S. Conkling, Director, Bureau of Venereal
Disease Control.
11:00 A. M. Housing and Health — E. H. Sands,
State Housing Commissioner.
2:00 P. M. What the Health Officer Should
Know About a Sewage Disposal Plant — Hans Z.
Pedersen, Sanitary Engineer, State Board of Health.
3:00 P. M. The Diagnostic Work of the State
Board of Health Laboratory — R. L. Laybourn, As-
sistant Director, State Board of Health Laboratory.
3:00 P. !M. Inspection of Diagnostic Laboratories
and Health Exhibits.
Friday, July 21
9:00 A. M. Public Health Education and the
-Sheppard-Towner Act — O. E. Klingaman, Director,
E.xtension Division and Division of Maternity and
Infant Hygiene.
10:00 A. M. Milk Supplies and Their Relation to
Public Health — Earle L. W’aterman, Associate Pro-
fessor of Public Health, Extension Division.
11:00 A. M. Public Health Nursing — Miss He-
lena Stewart, Director, School of Public Health
Nursing.
2:00 P. M. Tuberculosis as a Public Health Prob-
lem— Dr. H. V. Scarborough, Superintendent Oak-
dale Sanitarium.
3:00 P. M. Inspection of the State Tuberculosis
Sanitarium at Oakdale.
NOTES
Room Reservations — W’ire, write or telephone to
Professor O. E. Klingaman, Director of the Exten-
sion Division for room reservations.
Registration — All registrations will be made on the
second floor of the Medical Laboratory Building at
the corner of Dubuque and Jefferson streets. There
are no fees charged to residents of the state.
Place of Meeting — All meetings will be held in
Room 201, Medical Laboratory Building.
Exhibits — .An exhibit of laboratory apparatus,
models, charts, and forms used in public health work;
will be displayed in the hall on the second floor of
the Aledical Laboratory Building.
MALIGNANT GROWTHS DEVELOPING IN
UNDESCENDED TESTICLES
Dr. John H. Cunningham of Boston, in a paper on
the above named subject, published in The Journal
of L^rology, May, 1921; says in regard to malignant
disease of the testicles that the prognosis as in all
malignant testicular tumors is bad and the mortality
high.
The majority of the patients in this recorded series
were dead within one year following operation and
Buckley states that only three of the fifty-nine pa-
tients which he recorded were alive after two years.
Hinnman has pointed out that metastasis from a
malignant tumor of the testicle may always be ex-
pected to take place in the lumbar lymph nodes, par-
ticularly in the nodes in the region of the renal ped-
icle when the tumor is on the right side, and to the
left of the aorta when the growth is located in the
left testicle. Hinnman had advocated the removal of
these nodes in connection with orchidectomy when
these nodes are not clinically involved; basing this
opinion upon the fact that but 15 to 20 per cent of
patients with testicular new growth are cured by
orchidectomy even before metastasis have taken
place.
The principles underlying the use of electricity in
medicine are but feebly understood by the majority
of its followers. Manufacturers are anxious to pro-
duce apparatus to obtain results such as are expected
and obtained by experts in this line — but here their
mission stops, and it is from the writers of books and
articles on the subject that the physicians must get
further and essential information.
It is the earnest desire of every physician using
apparatus to produce not only the best possible re-
sults for his patients, but to take care of his own
financial returns, as well. .A heart-to-heart talk, not
only explaining the reasons why certain electrical
modalities are used, but the technical application, is
an occasion that should be appreciated by those who
desire to become more familiar with their special
apparatus, and better acquainted wdth the methods
applicable to a greater variety of diseases.
Such diseases and conditions as arise from what
are commonly known as constipation, intestinal indi-
gestion and auto-intoxication — but recognized in the
newer term of intestinal statis — will be considered at
length in Doctor Morse’s clinics and illustrations.
High blood-pressure, and the relief of its many ac-
companying symptoms, will be especially considered.
The use of the constant current in gynecology has
much more importance than is usually attributed to
it because of the lack of familiarity with the subject.
The opportunity of questioning the lecturer may be
the means of helping some physician on a puzzling
case.
We are preparing for your attendance at these
clinics, as fully outlined on the program herewith.
H. G. Fischer & Co., Inc.
274
Journal of Iowa State Medical Society
Minutes of the Iowa State Medical Society
Seventy-first Annual Session, Des
Moines, May 10, 11, 12, 1922
Wednesday, May 10, Morning
The Seventy-first Annual Session of the Iowa
State Medical Society was held in Fort Des Moines
Hotel, Des Aloines, May 10, 11 and 12, 1922.
The Society was called to order at 8:45 o’clock by
the President, Dr. Alanson !M. Pond, Dubuque. Fol-
lowing invocation by Rev. Father V. Stoll, Des
Moines, Dr. Alva P. Stoner, Des Moines, President
of the Polk County Aledical Society, on behalf of the
local profession extended to the visiting members an
address of welcome, response being made by Dr.
Wm. L. Allen, Davenport.
Dr. Harold L. Brereton, Emmetsburg, read a pa-
per on “Pyloric Stenosis of Infancy.” Discussed by
Drs. M. L. Turner, Des Moines; L. E. Kelley, Des
Moines; E. B. Wilcox, Oskaloosa; E. E. Morton,
Des ^Moines; A. H. Byfield, Iowa City, and by Dr.
Brereton in closing.
The President stated that the Iowa State Pharma-
ceutical Association had requested that the Iowa
State Medical Society appoint a committee to co-
operate with a committee of that Association in mat-
ters of mutual interest.
It was moved that the chair appoint a committee
of three to confer with the Iowa State Pharmaceuti-
cal Association in matters of mutual interest. The
motion was duly seconded, and carried.
The President appointed as such committee Drs.
R. L. Parker, Des Moines; P. E. Somers, Grinnell,
and Leonard Fraser, Bradford.
Dr. Frederick G. Murray, Cedar Rapids, read a
paper on “Market Milk from a Medical Standpoint.”
Discussed by Drs. Daniel C. Steelsmith, Dubuque;
D. N. Loose, Maquoketa; Fred Moore, Des ^loines;
Edward P. Davis, Philadelphia; Granville N. Ryan,
Des Moines, and A. H. B3'field, Iowa City; Dr.
Murra\' closing the discussion.
On behalf of the Societjq Dr. D. C. Brockman, Ot-
tumwa, presented to President Pond the emblem of
his authority in the form of a beautiful gav'el, stating
that by its use during the meeting he might exer-
cise his prerogative of being the onh^ and official
knocker. In a brief address the President expressed
his thanks to the Society- for the memento.
Dr. Paul -A. White, Davenport, read a paper on
“Surgery of the Thyroid Gland.” Discussed by Drs.
George Kessel, Cresco; John F. Herrick, Ottumwa,
and by Dr. White in closing.
.Address on “Medical Ideals” was given b}' Dr.
Evan S. Evans, Grinnell, Chairman of the Section on
Medicine.
Dr. Oliver J. Fay, Des Aloines; read a paper on
“Injuries to the Spine not Involving the Cord.”
Dr. John W. Martin, Des Moines, read a paper on
“Vertebral Fractures with Cord Involvement.”
These two papers were jointly discussed by Drs.
William Tepson, Sioux Cit\'; H. C. Eschbach, Albia,
[July, 1922
and Tom B. Throckmorton, Des Moines, Dr. Fay
closing the discussion.
Wednesday, May 10, Afternoon
The meeting was called to order at 1:30 o’clock by
the President.
Dr. Bert L. Eiker, Leon, gave the “Oration in
Medicine.”
Dr. Walter L. Bierring, Des Aloines, read a paper
on “Subacute Bacterial Endocarditis.” Discussed bj-
Drs. Campbell P. Howard, Iowa City; C. F. Wahrer,
Fort Aladison; E. T. Edgerly, Ottumwa; Frank AI.
Fuller, Keokuk; Julius S. Weingart, Des Aloines;
-A. D. Woods, State Center; Daniel J. Glomset, Des
Aloines, and by Dr. Bierring, in closing.
Dr. Henry A. Christian, Professor of Aledicine,
Harvard Universitjq Boston, gave the Address on
Aledicine, his subject being: “Digitalis Results in
Certain Types of Cardiac Disease” (with lantern
demonstration ).
Dr. Clj'de A. Boice, Washington, read a paper on
“Aluscle Rigidity: Its Diagnostic Value.” Discussed
bj- Dr. Peter A. Bendixen, Davenport, and Dr. Boice
in closing.
President Pond retired to attend the meeting of
the House of Delegates, Vice-president, S. A. Spil-
man, presiding during the remainder of the session.
Dr. Jasper L. Augustine, Ladora, read a paper on
“Fracture of the Patella.” Discussed by Drs. Whit-
field W. Hansell, Grinnell; A. P. Donahue and Peter
A. Bendixen, Davenport, and William Jepson, Sioux
CitjL
Wednesday, May 10, Evening
Following the annual banquet of the Society and
its guests, an address on “Personalitj*” was-given b}-
Rev. W. C. Bitting, St. Louis. In the course of his
talk Dr. Bitting paid a tribute to the professional
spirit and guiding genius of the honored and beloved
member of the profession of Iowa, Dr. James Tag-
gart Priestley, concurrence in which was imme-
diately manifested b\- an ovation spontaneously and
unanimoush' extended to Dr. Priestley.
Thursday, May 11, Morning
The meeting was called to order at 9 o’clock by
President Pond.
Paper on “A Survdj' of Two Hundred Cases of
Pulmonary Tuberculosis,” by Dr. John W. Shuman,
Sioux City, in the absence of the author was read bj'
Dr. Roj' Woodward, Alason Cit}'. Discussed by Drs.
Herbert V. Scarborough, Oakdale, and J. W. Kime,
Fort Dodge, Dr. Woodward closing the discussion.
Dr. Lafe H. Fritz, Dubuque, read a paper on “Sur-
gical Diagnosis of Gall-Bladder Disease.” Dis-
cussed bj' Drs. S. A. Spilman, Ottumwa; E. C. Jun-
ger. Soldier; Alurdoch Bannister, Ottumwa; Walter
L. Bierring, Des Aloines; C. F. Wahrer, Fort Aladi-
son; Donald Alacrae, Council Bluffs, and H. J. Pren-
tiss, Iowa City, Dr. Fritz closing the discussion.
Dr. Henry J. Prentiss, Iowa City, read a paper on
“Some A'ariations in the Thoracic Content as Ob-
served in the Anatomical Laboratories of the State
VoL. XII, Xo. 7]
Journal of Iowa State Medical Society
275
University.” Discussed by Drs. Walter L. Bierring;
William Jepson, and Henry J. Prentiss in closing.
Dr. Aram G. Hejinian, Anamosa, read a paper on
‘‘Spreading Peritonitis and its Treatment.” Dis-
cussed by Drs. M. J. Kenefick, .Algona, and Donald
Macrae, Council Bluffs, Dr. Hejinian closing the dis-
cussion.
Dr. William Jepson, Sioux City, read a paper on
“Tumors of the Breast.” Discussed by Drs. Wm. L.
Allen, Davenport; Edward P. Davis, Philadelphia;
Paul A. White, Davenport, and Dr. Jepson, in
closing.
At the suggestion of Dr. Jepson, a rising vote of
thanks was extended to Dr. Davis for participating
in the discussion.
Dr. Judd C. Shellito, Independence, read a paper
on “Diagnostic Problems in the Right Upper Quad-
rant.” Discussed by Drs. Donald Macrae and Tom
B. Throckmorton, the essayist closing the discussion.
Thursday, May 11, Afternoon
The meeting was called to order at 1 :30 o’clock by
the President.
Dr. Pearl E. Somers, Grinnell, read a paper on
“Chemistry and Medicine.’’
At the conclusion of his paper Dr. Somers moved
that the House of Delegates be requested to take
action leading to the appointment of a committee
from this Society, whose duty it shall be to carry to
the American Medical Association meeting at St.
Louis the feeling of the Iowa State Medical Society
that a Chemo-Medical Research Institute is vital to
the growth of Medicine, and that we are keenly anx-
ious that the American Medical Association take im-
mediate action looking towards its realization.
The motion was seconded, and carried. The Pres-
ident announced that the matter would be referred
to the House of Delegates.
Dr. Somers’ paper was then discussed by Drs. Rob-
ert L. Parker, Des ^Moines, and Frank !M. Fuller,
Keokuk, the essayist closing the discussion.
Address on “The Control of the Circulation,” was
presented by Dr. George Kessel, Cresco, Chairman
of the Section on Surgery.
The Address on Surgery — “Our Present Knowl-
edge and Experience Concerning Caesarean Section”
(with lantern demonstration) — was given by Dr. Ed-
ward P. Davis, Professor of Obstetrics, Jefferson
Medical College, Philadelphia.
On motion of Dr. Paul E. Gardner, New Hamp-
ton, paper entitled, “Extraperitoneal Caesarean Sec-
tion,” by Dr. Nicholas Schilling, New Hampton, ow-
ing to the unavoidable absence of the author was
read by title and passed with recommendation that
it be published.
Dr. Lena A. Beach, Rockwell City, read a paper
on “Multiple Sclerosis. “ Discussed by Drs. Clarence
E. Van Epps, Iowa City, and Frank A. Ely, Des
Moines, Dr. Beach closing the discussion.
Dr. John F. Herrick, Ottumwa, read a paper on
“Spinal Puncture as an Aid to Diagnosis and Ther-
apeusis.” Discussed by Dr. Joseph W. Rowntrec,
Waterloo, and Dr. Herrick in closing.
Dr. Howard I-. Beye, Iowa City, read a paper on
“Differential Diagnosis between Infection of Bone
and Sarcoma of Bone” (lantern demonstration). Dis-
cussed by Drs. Donald iMacrae, Jr., Council Bluffs,
and Howard L. Beye.
Thursday, May 11, Evening
The meeting was called to order at 8:15 o’clock by
Vice-President Spilman.
President Alanson ]\I. Pond then read his Address,
entitled — “Some Recent Aledical Problems in Iowa.”
Dr. James ^IcDowell Patton, Omaha, guest of the
Section on Ophthalmology, Otology and Rhinolaryn-
gology, gave an address on “The Pros and Cons of
Foreign Protein Injections in Affections of the Eye.”
Friday, May 12, Morning
The meeting was called to order at 9 o’clock by
\’ice-President Spilman.
Dr. James G. Macrae, Creston, read a paper on
“Plastic Medicine.’’ Discussed by Drs. Paul A.
White, Davenport, and J. W. Kime, Fort Dodge.
Dr. Cyril G. Field, Fort Dodge, read a paper on
“Anterior Poliomyelitis: A Review of Thirty Spor-
adic Cases.” Discussed by Dr. Frank A. Ely, Des
^loines, and Dr. Field in closing.
Dr. Harry E. Pfeiffer, Cedar Rapids, read a paper
on “The Postoperative Treatment of Peritonitis.”
Discussed by Dr. Ralph E. Keyser, Marshalltown,
and Dr. Pfeiffer in closing.
The House of Delegates having adjourned. Presi-
dent Pond presided during the remainder of the
meeting.
The Oration on Surgery was given by Dr. Charles
E. Ruth, Des Moines.
Report of the transactions of the House of Dele-
gates was then presented by the Secretary. Upon
motion, unanimously carried, the report was ac-
cepted.
SUMMARY OF PROCEEDINGS OF THE
HOUSE OF DELEGATES
“At the sessions of the House of Delegates which
took place during the first two days of the meeting,
the time was largely consumed in taking care of the
routine work. The reports of the various officers
and committees were received and placed on file.
On the second day the w'ork of the Field Activities
Committee was presented by its chairman. Dr. Frank
E. Sampson of Creston. On account of the nature
of the report of this committee, and in accordance
with the By-Laws of the Society, the report was laid
upon the table for one day.
At the session this morning the Nominating Com-
mittee presented its report, whereupon the following
officers were elected for the ensuing year:
President-Elect, Oliver J. Fay, Des Moines.
First Vice-President, George Kessel, Cresco.
Second Vice-President, O. F. Parish, Grinnell.
276
Journal of Iowa State Medical Society
Re'-elected on the Board of Trustees; J. W. Cok-
enower, Des ^loines.
Delegates to the A. M. A.; Donald Macrae, Jr.,
Council Bluffs; Wm. L. Allen, Davenport. (Holding
over.) J. C. Rockafellow, Des Moines.
Alternate Delegates to the A. M. A.: D. X. Loose,
Maquoketa; Bert L. Eiker, Leon. (Holding over.)
M. X. Voldeng, Woodward.
The resolution, recommending the appropriation
of a sum of money not to exceed $7,500 for the work
of the Field Activities Committee during the coming
year, was unanimously passed.
For the place of meeting of the Seventy-second
.\nnual Session of the Society, Ottumwa was chosen,
the time selected being May 9, 10, 11, 1923.
The registration of the session shows the presence
of 675 physicians, visiting ladies and guests.”
Tom B. Throckmorton,
Secretary.
President-Flect Charles T. Saunders, Fort Dodge,
was then inducted into office as President of the
Iowa State Medical Society.
With permission of the House, Dr. W. F. Sanders,
Des Moines, introduced and moved the adoption of
the following resolutions:
RFSOLUTIOXS
Resolved, That the Iowa State Medical Society
hereby extends its greetings to the following mem-
bers who by reason of disabilit}' or disease are pre-
vented from attendance upon this meeting, and ex-
presses the hope that they may be speedih' re-
stored to health and association among us:
Drs. A. G. Field, Des Moines; Fdward Hornibrook,
Cherokee; J. X. Warren, Sioux City; J. D. Brook-
ings, Woodward; A. L. Brooks, Audubon; J. M.
Brooks, Des Moines; G. X. Xewsome, Indianola; H.
B. Young, Burlington; George F. Crawford, Cedar
Rapids.
And Be It Further Resolved, That a copy of these
resolutions be sent b>^ the Secretary of this Society
to each of the above named members.
The motion was seconded, and unanimously car-
ried.
Upon motion, the meeting adjourned.
Tom B. Throckmorton,
Secretary.
Transactions House of Delegates
Iowa State Medical Society
Seventy-first Annual Session, Des Moines
May 10, 11, 12, 1922
First Meeting, Wednesday, May 10
The House of Delegates met in the Oak Dining
Room, Hotel Fort Des Moines, and was called to
order by the President, Dr. .\. M. Pond, at 3:30 p. m.
Roll call showed the presence of thirteen officers
and thirty-eight delegates, a total of fifty-one. A
[July, 1922
quorum being present, the House proceeded to the
transaction of business.
The Secretary, Dr. Tom B. Throckmorton, pre-
sented his annual report, which upon motion was
accepted and referred to the Finance Committee.
REPORT OF THE SECRETARY
To the Members of the House of Delegates of the
Iowa State Medical Society:
The following report for the year 1921-22 is re-
spectfullj' submitted:
The routine work in the Secretary’s office has
varied but little, if any, from that of former years.
The whole hearted support of the officers, together
with cooperation on the part of the vast majority of
the Secretaries of the various Component County
Medical Societies, has made the secretarial work
pleasant, agreeable, and, I trust, of value to organ-
ized medicine as a whole.
Membership
The membership of the Society still continues to
compare favorably with that of former years. In
1918, there was a total of 2185 members; in 1919,
2,205; in 1920, 2,340 members; and the past year 2,371
members. Every year brings a large quota of new
members into the Society, but, unfortunately, a num-
ber of doctors, some who have been members for
years, for some unknown cause, allow their member-
ship to lapse, so that the total gain every year is not
what, in reality, it should be. And while the mem-
bership for 1921 shows only a slight increase over
that of the year 1920, still it is gratifying to know
that organized medicine is on the increase, and that
there is an honest desire on the part of the compo-
nent county medical societies to receive every eligi-
ble and reputable medical man into fellowship with
all the rights and privileges appertaining thereunto.
To date the 1922 paid membership numbers 2,174.
American Medical Association
It is likewise agreeable to note that our national
body — The American Medical .Association — has not
been backward in the adoption of a policy similar to
the one suggested by Ex-President Macrae in his ad-
dress of last year.
Delightfully pleasing also is it to note the in-
creased activities of our national society during the
past year. If you will pardon what may seem to
be a digression from the usual Secretarial Report, I
would like to briefly touch upon one or two salient
points that I believe are of paramount value to
-American medicine as a whole, and to Iowa medicine
in particular.
The American ^ledical .Association for some time
has felt the need of closer relationship between the
various state societies and itself. With the object in
view of bringing this about, the board of trustees of
the national association authorized the calling to-
gether of the secretaries of the various state or-
ganizations for a conference in Chicago last Xo-
vember. .At this meeting, in an informal way, a
VoL. XII, No. 7|
Journal of Iowa State Medical Society
277
mutual exchange of ideas took place between tliosc
representing the welfare of our national association
and those having to do with the secretarial work of
state medical societies. So successful was the Con-
ference, so enthusiastic its participants, that the
Board of Trustees of the American Medical Asso-
ciation has assured the repetition of the Conference,
possibly as a yearly affair. That the future of
American medicine would be the better safeguarded
by the continuation of such annual conferences, is,
1 am sure, quite obvious.
Field Activities
As a direct outgrowth of desire on the part of our
national organization to be of more help to the va-
rious state societies, a field activities man. Dr. Olin
West of Tennessee, has been, recently, appointed by
the Board of Trustees of the American Medical As-
sociation to fill the newly created office.
Dr. West has already given assurance that he is
more than anxious to be of any service in aiding and
abetting a closer cooperation between organized
medicine in Iowa and the home association in Chi-
cago. This would seem to indicate the beginning of
a new era in American medicine — a national field ac-
tivity man, and, if our national association has seen
fit to so place at our disposal the service of such a
department, is it udreasonable or illogical to assume
that Iowa medicine would be injured or harmed by
having the services of some individual, or individuals,
who will honestly endeavor to coordinate and bring
into harmonious relationship, the medical activities
of the various counties of the state' With every
county properly organized and functioning in all its
medical activities, a stronger, a better, a larger,
state medical society is assured, and in just such pro-
portion as the state medical societies are function-
ing and efficient, will our national association grow
in strength and efficiency.
The willingness of the American Medical Associa-
tion to extend to the Iowa State Medical Society the
services of its various departments, seems to me to
be a friendly challenge, and it is largely up to this
bod}', the House of Delegates, here assembled, as to
what will be accomplished, during the coming year,
as to a better understanding, a more thorough coor-
dination, and a more harmonious cooperation be-
tween the medical activities of the various Compo-
nent County Medical Societies, the Iowa State Med-
ical Society, and the American Medical Association.
Other matters in which the office of Secretary has
been active, are reported to the House of Delegates
from other sources.
FINANCIAL STATEMENT
May 1, 1921 to April 30, 1922
Receipts
Dues, 1920 $ 10.00
Dues, 1921 1,355.00
Dues, 1922 10,333.00
Advertising 7,441.78
Reprints 634.28
Subscriptions — non-members 86.85
Sales 10.84
Honorarium — A. M. A. Adver-
tising Bureau 192.00 $20,063.75
Disbursements
Commission and Discount to
Advertising Bureau $ 893.40
Dr. Thos. F. Duhigg, Treas 19,170.35 $20,063.75
The following orders have been issued during the
year;
No. Amount
1127 Salary office assistant, .\pril $ 100.00
1128 Iowa Press Clipping Bureau, April 5.00
1129 American Medical Association, 1921
Directory 12.00
1130 American Badge Co., Chicago badges
1921 Session 80.80
1131 Lewis Schooler, postage and expense
medico-legal committee, 1920-21 10.00
1132 Dr. Wm. S. Windle, Oskaloosa, for lo-
cal attorney fee, medico-legal 75.00
1133 Central Engraving Co., cuts, April
and May issues 13.28
1134 Plumb Jewelry Co., engraving gavel.... 6.00
1135 J. H. Welch Prtg. Co., April issue
and reprints 966.30
1136 J. W. Cokenower, Chrm. Legislative
Co., Dahlberg Dup. Co 79.68
1137 Dahlberg Duplicating Co., printing re-
port Legislative Com. and mailing 32.03
1138 J. W. Cokenower, Chrm. Legislative
Com. stenographic services and as-
sistant at legislative session 113.85
1139 Thos. F. Duhigg, Treas., salary, post-
age and expense 1920-21 163.93
1140 Samuel Bailey, Councilor, expenses 8.06
1141 Paul E. Gardner, Chairman Council,
expenses 7.00
1142 Dutcher & Davis, Attys, medico-legal
January, February, March 483.18
1143 Tom B. Throckmorton, Sec’y, balance
salary office assistant 1920-21 100.00
1144 Tom B. Throckmorton, Sec’y, second-
class postage, city delivery, salary
2-15-21 to 5-15-21 133.00
1145 Tom B. Throckmorton, Sec’y, e.x-
penses 1921 Session including hotel
for guests and registration 203.59
1146 Central Engraving Co., cuts for Jour 10.75
1147 Ida J. Brinton, Transactions House of
Delegates 25.00
1148 Dr. Tom B. Throckmorton, salary of-
fice assistant for May 120.00
1149 Mathias Metz Co., Dubuque, stationery
for President Pond 19.25
1150 J. H. Welch Prtg. Co., May issue and
reprints 615.75
1151 Iowa Press Clipping Bureau, May 5.00
278
Journal of Iowa State Medical Society
[July, 1922
No. Amount
1152 Central Engraving Co., cuts July issue 5.53
1153 Tom B. Throckmorton, Sec'y, salary
.office assistant, June 120.00
1154 D. S. Fairchild, Editor, salary, April
to July, Sec'y’s salarj-, postage 408.64
1155 J. H. Welch Prtg. Co., June Journals,
May and June reprints 654.05
1156 Tom B. Throckmorton, Sec’y, salary
office assistant, July 120.00
1157 Central Engraving Co., cuts, August
issue 5.00
1158 Federal Printing Co., stationery for
Editor 21.61
1159 Iowa Press Clipping Bureau, June and
July 10.00
1160 McNamara Office Supply Co., sup-
plies for Secretarj- 3.75
1161 Bankers Prtg. Co., stationery, Sec’j' 6.00
1162 C. L. Dahlberg Co., form letters. Sec-
tary’s office 6.68
1163 Upham Bros., bonds for Secretary
and Treasurer 62.50
1164 Miss Adelaide Folsom, reporting 1921
Session 161.60
1165 J. H. Welch Prtg. Co., July and Au-
gust Journals and reprints 1,648.47
1166 Dunshee & Brody, Des Moines, at-
torney fees medico-legal 50.00
1167 Butcher & Davis, attys, Iowa City,
medico-legal April, ^lay and June 533.87
1168 Dr. Edwin Jackson, Denver, expense
attending 1921 Session 71.28
1169 Dr. Tom B. Throckmorton, Sec'y, of-
fice assistant salary, August 120.00
1170 Dr. Tom B. Throckmorton, Sec’y,
second-class postage, rent, phone, etc.,
for Jvlay, June, July and August, salary
5-15 to 8-15, 1921 246.73
1171 T. E. Powers, Clarinda, expense at-
tending August trustees’ meeting 15.95
1172 W. B. Small, Waterloo, expense at-
tending August trustees’ meeting 9.42
1173 J. W. Cokenower, expense August
meeting trustees 7.90
1174 Tom B. Throckmorton, Sec’y, salary
office assistant. Sept 120.00
1175 D. S. Fairchild, Editor, salary, Sec’y’s,
salary-, postage July, .\ugust and Sept. 410.48
1176 Iowa Loan & Trust Co., Des Moines,
school bond purchase 1,909.16
1177 Iowa Press Clipping Bureau, August
and September 10.00
1178 J. H. Welch Prtg. Co., Sept. Journals
and reprints 640.30
1179 Tom B. Throckmorton, salary office
assistant, October 120.00
1180 Central Engraving Co., cuts for De-
cember issue 15.56
1181 Donald Macrae, Jr., expense as Pres 50.00
1182 Bankers Prtg. Co., order books. State
Society 11.65
No. Amount
1183 Federal Prtg. Co., 1922 members re-
ceipts, stationery, envelopes for State
Society and Journal 61.25
1184 American Medical Association, 1921
membership cards 3.50
1185 C. L. Dahlberg Co., form letters 1.15
1186 McNamara Office Supply Co., sup-
plies for Secretary’s office 10.90
1187 C. V. Mosbj' Co., cuts for Journal use 2.50
1188 Tom B. Throckmorton, Sec’y, salary
office assistant, November 120.00
1189 Tom B. Throckmorton, Sec’y, rent
and phone Sept, to Dec., second-class
postage, salary 8-15-21 to 11-15-21 246.29
1190 J. H. Welch Prtg. Co., Oct. and Nov.
Journals and reprints 1,259.10
1191 Butcher & Hambrecht, attys., Iowa
City, medico-legal July to October 1,081.47
1192 Robert M. Elaines, atty., Des iMoines,
local attorney, medico-legal 355.73
1193 H. F. Barthell, atty.. Decorah, local
attorney, medico-legal 125.00
1194 C. E. Cooper, attorney, Onawa, local
attorney, medico-legal 132.70
1195 Dunshee & Brody, attys., Des Moines,
local attorney medico-legjU 20.00
1196 Iowa Press Clipping Bureau, October
and November service 10.00
1197 Thos. F. Duhigg, deficit Arrangement
Committee 1921 17.35
1198 W. B. Small, Waterloo, expense at-
tending November meeting Trustees 10.86
1199 T. E. Powers, Clarinda, expense at-
tending November meeting Trustees 15.60
1200 J. W. Cokenower, Chrm. Trustees, sta-
tionery stamps, expense of November
meeting. Trustees 14.40
1201 Tom B. Throckmorton, Sec'y., salary
assistant for December 120.00
1202 D. S. Fairchild, Editor, salary, secre-
tary and postage for October, Novem-
ber and December 410.80
1203 Central Engraving Co., cuts for Janu-
ary issue 10.17
1204 Iowa Press Clipping Bureau, Decem-
ber 5.00
1205 Tom B. Throckmorton, Sec’y, salary
assistant for January 120.00
1206 Iowa Press Clipping Bureau, January
and February 10.00
1207 C. L. Dahlberg Co., Sec’y. form letters
to County Secretaries 2.48
1208 American Medical Association, 1922
membership and record cards 17.50
1209 Federal Prtg. Co., Journal wrappers
and stationery State Society 89.00
1210 J. H. Welch Prtg. Co., December Jour.
and reprints 720.35
1211 Butcher & Hambrecht, attys, Iowa
City, medico-legal Oct., Nov., Dec 1,085.25
\’0L. XII, No. 7J
J0URN.A.L OF Iowa State Medical Society
279
Xo. Amount
1212 Kindig, McGill, Stewart & Hatfield,
attorneys, Sioux City, medico-legal 50.00
1213 Gerritt Klay, atty.. Orange City, med-
ico-legal 150.00
1214 Tom B. Throckmorton, Sec’y, rent,
phone, second-class postage, salary
11-15-21 to 2-15-22 253.45
1215 T. E. Powers, Clarinda, expense at-
tending February Trustees meeting 15.04
1216 W. B. Small, Waterloo, expense at-
tending February Trustees meeting 10.18
1217 J. W. Cokenower, expense, February
meeting Trustees and medico-legal 9.70
1218 H. B. Jennings, Council Bluffs, ex-
pense attending February meeting
Trustees and medico-legal Committee 10.90
1219 J. H. Welch Prtg. Co., January Jour 467.80
1220 J. H. Welch Prtg. Co., Jan. reprints.... 45.15
1221 Tom B. Throckmorton, Sec’y, salary
office assistant, February 120.00
1222 J. H. Welch Prtg. Co., February Jour.
and reprints 534.55
1223 Tom B. Throckmorton, Sec’y, office
assistant, March 120.00
1224 Central Engraving Co., cuts for April
issue 9.40
1225 Dr. D. S. Fairchild, Editor, salary
stenographer, postage, Jan., Feb., Mch. 412.05
1226 Bastian Bros., Rochester, N. Y., 1922
badges 70.16
1227 J. H. Welch I’rtg. Co., March Journal
and reprints 550.50
Tom B. Throckmorton,
Secretary.
JOURNAL STATEMENT
January 1, 1921 to December 31, 1921
. Income
.\dveriising $7,830.15
Reprints 419.30
Subscriptions — non-members 68.20
Sales 30.81
Honorarium from A. M. A. Ad-
vertising Bureau 192.00
Subscriptions 1919 and 1920
members 17.00
Subscriptions 1921 members to
:May 15 2,105.00
Subscriptions 1921 members
from May 15 (244 members
at $2.00) 488.00 $11,150.46
Expenses
Printing —
2- 64 page Journals.... $1,094.75
68 page Journals.... 2,963.65
2- 72 page Journals.... 1,226.70
1- 84 page Journal .... 803.00
1- 76 page Journal .... 652.85
1-100 page Journal .... 939.92
Total 872 pages
$7,680.87
Journal wrappers
.$ 90.00
Engravings
63.87
Commission and discount
. 907.78
Reprints
. 503.05
Second-class postage ami city de-
livery
162.76
News service
60.00
Postage
30.00
Editor’s postage and office e.x-
pense
24.92
Office supplies
40.25
Rent and telephone
. 115.02
Editor’s secretarv
60.00
Business office assistant’s salary
■ 697.00
Editor’s salarv
. 1,500.00
Deficit 785.06
$11,150.46
Tom B. Throckmorton,
Business Manager.
REPORT OF TRE.-VSURER
Dr. Thos. F. Duhigg, Treasurer, presented his an-
nual report which, upon motion, was accepted and
referred to the Finance Committee.
Balance Sheet
Balance on hand .^pril 30, 1921 $32,225.44
Received from Secretary 19,170.35
School Bonds ($2000) purchased
for 1,909.16
Interest on $20,000 Liberty
Bonds 850.00
Interest on school bond 50.00
Interest on deposits 219.23
Total receipts to Apr. 30, 1922 $54,424.18
Expended as per orders here-
with attached .t $19,871.81
Less check No. 654 (Welch
Prtg. Co., not yet presented
for payment) 550.50
Total expended $19,321.31
Assets
Liberty Bonds $10,000.00
Liberty Bonds $10,000 purchased
at 8,600.00
Trade acceptance paper (Morris
bank) 2,002.96
School bond ($2,000) purchased
for 1,909.16
On time deposit People’s Sav-
ings Bank 10,734.70
On deposit subject to check 1,856.05
Total on hand April 30, 1922....$35,102.87 $54,424.18
280
Journal of Iowa State ^Medical Society
[July, 1922
Des Moines, Iowa, May 3, 1922.
To Whom It May Concern:
This is to certify that Doctor Thomas F. Duhigg,
Treasurer of the Iowa State Medical Society, has
left the following bonds for safe keeping: ($20,000
Liberty loan bonds, $2,000 consolidated Independent
School District of Meriden, Iowa. He also had to
his credit as Treasurer $10,734.70 in savings account
and $1,856.05 in checking account at the close of
business April 30, 1922.
PEOPLE’S SAVINGS BANK,
Carl \V. ^lesmer.
Asst. Cashier.
Expenditures of the Iowa State ^ledical Society,
1921-
-22.
No.
1921
Amount
550
.5-17
Dr. T. B. Throckmorton, Sec.
salary, office assistant $
100.00
551
.--17
Thos. F. Duhigg, salary,
stamps, miscellaneous
163.93
552
.--17
Iowa Press Clipping Bureau,
April News Service
5.00
553
5-17
American Med. Association,
Copy 1921 A. M. A. Directory
12.00
554
5-17
American Badge Co., 1921
badges
80.80
.555
5-17
Dr. Lewis Schooler, postage,
stationery, miscellaneous
10.00
556
5-17
Dr. W’m. S. Windle, attorney’s
fees i
75.00
557
5-17
Central Engraving Co., half
tones April-Mav
13.28
558
5-17
Plumbs Jewelry Store, engrav-
ing President’s gavel
6.00
559
5-17
A\'elch Prtg. Co., April Journal
and reprints
966.30
560
.--17
Dr. J. W. Cokenower, payment
Dahlberg Duplicating Co
79.68
561
5-17
Dahlberg Duplicating Co., copy
report, Legislative Committee
32.03
562
.--17
Dr. J. W. Cokenower, payment
Dahlberg Duplicating Co., and
stenographer
113.85
563
-5-17
Dr. Samuel Bailey, trip, Os-
ceola, 3-28-21, councilor
8.06
564
.5-17
Dr. Paul Gardner, expenses
as eouncilor
7.G0
565
.--17
Dutcher & Davis, Jan., Feb.,
!March, medico-legal service
483.18
566
5-17
Dr. T. B. Throckmorton, Sec.,
salary, office assistant
100.00
567
5-17
Dr. T. B. Throckmorton, Sec.,
salary, postage, miscellaneous
133.00
568
5-28
. Dr. T. B. Throckmorton, Sec.,
expenses General .Session
203.59
569
6- 8
Central Engraving Co., half
tones, zinc etchings
10.75
570
6- 8
Ida J. Brinton, transactions
House of Delegates 1921
25.00
571
6- 8
Dr. T. B. Throckmorton, Sec.,
salary, office assistant, Mav
120.00
No.
1921
Amount
572
6- 8
^klathis !Metz Co., letter heads
President’s office
19.25
573
7- 5
Welch Prtg. Co., May Journal
615.75
574
7- 5
Iowa Press Clipping Bureau,
^lay service
5.00
575
7- 5
Central Engraving Co., half
tones Tulv issue
5.53
576
7- 5
Dr. T. B. Throckmorton, Sec.,
salary, office assistant, lune
120.00
577
7- 8
Dr. D. S. Fairchild, salary, 4-1
to 7-1-21, secretary’s service
408.64
578
7-19
Welch Prtg. Co., June Journal
and reprints
654.05
579
580
8- 4
Dr. T. B. Throckmorton, Sec.,
salary, office assistant, Tulv
Void
120.00
.-81
8-15
Central Engraving Co., half
tones, August issue
5.0')
582
9- 7
Federab Prtg. Co., printing for
Dr. Fairchild, Editor
21.61
583
9- 7
!McNamara-Kenworthy, office
supplies
. 3.75
584
9- 7
Iowa Press Clipping Bureau,
Tune and Tulv news service
10.00
585
9- 7
Bankers Prtg. Co., letter heads.
Secretary's office
6.00
586
9- 7
C. L. Dahlberg Co., form let-
ters, Tune, July, August
6.6H
587
9- 7
Upham Bros., bond, Secretary
and Treasurer
62.50
588
9- 7
Adelaide Folsom, reporting
1921 Session
161.60
589
9- 7
Welch Prtg. Co., July and Aug.
Tournals and reprints
1,648.47
590
9- 7
Dunshee & Brody, attorneys,
attorney fees
50.00
591 .
9- 7
Dutcher & Davis, attorneys,
medico-legal, April, May and
Tune
533.87
592
9- 7
Dr. Edward Jackson, Denver,
traveling expenses 1921 Session
71.28
593
9- 7
Dr. T. B. Throckmorton, .Sec.,
salary, office assistant, August
120.00
594
9- 7
Dr. T. B. Throckmorton, Sec.,
postage, rental, salary, etc
246.73
595
9- 7
Dr. T. E. Powers, expenses
.August meeting trustees
15.95
596
9- 7
Dr. W. B. Small, e.xpenses
August meeting trustees
9.42
.-97
9- 7
Dr. J. W. Cokenower, expenses
August meeting trustees
7.90
598
8- 5
Dr. T. B. Throckmorton, Sec.,
salary, office assistant. Sept
120.00
599
600
8- 5
Dr. D. S. Fairchild, salary,
July, -Aug., Sept., misc. exp
Void
410.48
601
602
10- 7
Iowa Loan & Trust Co., bonds
— Consolidated Independent
School District, Aleriden, la
A’oid
1,900.16
VoL. XII, Xo. 7|
Journal of Iowa State Medical Society
281
No.
1921
-Amount
No.
1922
Amount
603
10-18
Welch Prtg. Co., Sept. Journal
634
2-25
C. L. Dahlberg & Co., form
and reprints
640.30
letters
2.48
604
10-18
Iowa Press Clipping Bureau
635
2-25
-American Medical Association,
Service, Aug. and Sept
10.00
membership and record cards....
17..50
605
11- 9
Dr. T. B. Throckmorton, Sec.,
636
2-25
Federal Prtg. Co., letter heads.
salarv, office assistant Oct ..
120 00
etc
89.00
606
12- 6
Central Engraving Co., half
637
2-25
Welch Prtg. Co., Dec. Journal
tones
15.. 56
and reprints
720.35
607
12- 6
Bankers Printing Co., office
638
2-25
Chas. M. Dutcher, attorney.
supplies
11.65
medico-legal service
1,085.25
608
12- 6
Federal Prtg. Co., envelopes....
61.25
639
2-25
Kindig, McGill, Stewart and
609
12- 6
-American Medical -Assn., 1921
Hatfield, medico-legal service
50.00
membership cards
3.50
640
2-25
Gerrit Klay, medico-legal ser-
610
12- 6
C. L. Dahlberg & Co., form let-
vice
150.00
ters
1.15
641
2-25
Dr. T. B. Throckmorton, Sec.,
611
12- 6
McNamara & Kenworthv Co.,
salarv, rental, etc ;..
253.45
office supplies
10.90
642
2-25
Dr. T. E. Powers, expense trus-
612
12- 6
Mosby Book & Publishing Co.,
tees meeting 2-21-22
15.04
cuts Dr. Ruth's paper
2.50
643
2-25
Dr. W. B. Small, expense trus-
613
12- 6
Dr. T. B. Throckmorton, Sec.,
tees meeting 2-21-22
10.18
salarv, office assistant
120.00
644
2-25
Dr. J. W. Cokenower, expense
614
12- 6
Welch Prtg. Co., Oct. and Nov.
trustees meeting 2-21-22
9.70
lournals
1,259.10
'645
2-25
Dr. H. B. Jennings, expense
615
12- ,6
Dutcher & Hambrecht, attor-
trustees meeting 2-21-22
10.90
ne}' fees
1,081.47
646
3- 6
Welch Prtg. Co., Januarj- Jour.
467.80
616
12- 6
Robert M. Haines, attornev
647
3- 6
Welch Prtg. Co., reprints Jan.
fees
355.73
issue
45.15
617
12- 6
H. F. Barthell, attornev fees
125.00
648
3-31
Dr. T. B. Throckmorton, Sec.,
618
12- 6
C. E. Cooper, attornev fees
132.70
salarv, office assistant, Feb
120.00
619
12- 6
Dunshee & Brodv, attornev
649
3-31
Dr. T. B. Throckmorton, Sec.,
fees
20.00
salary, office assistant, March
120.00
620
12- 6
Iowa Press Clipping Bureau,
6.50
3-31
Welch Prtg. Co., Feb. Journal
Oct. and Nov. service
10.00
and reprints
534.55
621
12- 6
Dr. T. F. Duhigg, deficit enter-
651
4-10
Central Engraving Co., half
tainment fund
17.35
tones, April issue
9.40
622
12- 6
Dr. W. B. Small, e.xpense trus-
6.52
4-10
Dr. D. S. Fairchild, salary.
Jan., heb., March, misc. exp
412.05
LUUo IllUULXii X X
lU.oO
653
4-19
Bastian Bros., badges, 1922
623
12- 6
Dr. 1. E. Powers, e.xpense
•Session
70.16
trustees meeting 11-29-22
15.60
654
4-26
Welch Prtg. Co., March Tour.
624
12- 6
Dr. J. W. Cokenower, station-
and reprints
550.50
erv and stamps
14.40
655
Void
625 12- 6 Dr. Donald Macrae, expense as
President, 1921-22 50.00
626 12- 6 Dr. T. B. Throckmorton, Sec.,
postage, rental, etc 246.29
Total expended.
$19,871.81
Thos. F. Duhigg,
Treasurer.
No. 1922 Amount
627 1- 5 Dr. T. B. Throckmorton, Sec.,
salary, office assistant 120.00
628 1- 9 Dr. D. S. Fairchild, salary,
Oct., Xov., Dec., misc. expense 410.80
629 Void
630 1-16 Central Engraving Co., half
tones 10.17
631 1-16 Iowa Press Clipping Bureau,
December service 5.00
632 2- 3 Dr. T. B. Throckmorton, Sec.,
salary, office assistant 120.00
633 2-25 Iowa Press Clipping Bureau,
news service, Jan. and Feb 10.00
REPORT OF BOARD OF TRUSTEES
The report of the Board of Trustees was given by
the Chairman, Dr. I. W. Cokenower. Motion made
and duly seconded, that the report be received and
placed on file. Carried.
The report follows:
The reports of our Secretary and Treasurer show
our Society’s finances to be in good condition.
^lany of the State Medical Societies have been
compelled to increase their members annual dues in
order to make ends meet, but the Iowa State Medical
Society has not found this necessary, and has not
only broken even, but made an average gain of $4,-
282
Journal of Iowa State Medical Society
[July, 1922
545.23 each year from 1916-1917 to 1921-1922, or a
total gain for the six years mentioned of $27,271.38;
this added to our funds on hand, prior to the above
mentioned time, makes our present assets $35,482.62,
not including a well equipped office for our business
manager and assistant. The amount just mentioned
includes Liberty Bonds, (2) $20,000; Consolidated
School Bonds, $2,000; Des Moines Morris Plan Bank
$2,000; time deposits, $9,154.77; and checking account
(April 6, 1922), $2,327.95, all deposited in the People’s
Savings Bank, Des Moines, by our Treasurer.
These figures have been compiled for your in-
formation and not with a view of, or expecting any
change in our annual dues, but on the contrary to
emphasize the importance of not doing so, for rea-
sons explained later.
The increasing of our funds without increasing our
dues, prompted your board last November to give
our efficient Editor and Business Manager all the
needed space and additional pages to our Journal
necessary for advertising and reading matter — this
has increased our Journal from 64 pages, the original
contract, with our printer, to many pages more and
some issues nearly double that number of pages, as
well as materially increasing the cost, with the re-
sult that our Journal is equal to, if not the best.
State Medical Journal in the United States.
The past year’s net receipts used in averaging the
past six years income, has somewhat of a different
complexion from a financial viewpoint as compared
with the past, caused by the extra expense in printing
our Journal, and especially the amount paid our at-
torney and local attorneys in defending damage suits,
which amounted to $4,988, so that really we about
broke even. It is but due our worthy Defense Com-
mittee to state that they have worked hard to keep
the Defense expenses down and have done well, con-
sidering the amount of work done.
However, it is the purpose of your Board, through
our Editor and Business Manager to continue to im-
prove our Journal, so it will be a welcome, readable,
monthl}' visitor to your homes, and so attractive that
the doctors, who want to belong to our State Society,
but don’t want to pay for the Journal or contribute
to the Defense fund will be glad to do so.
J. \V. Cokenower, Chairman,
W. B. Small,
T. E. Powers,
Committee.
No report from the Council.
rE-^rt oe medico-legal committee
Dr. D. S. Fairchild, Chairman, presented the re-
port of the }kIedico-Legal Committee. It was moved
and seconded that the report be received and placed
on file. Carried.
The report follows;
Report of the Committee on Medical Defense
varies from year to year according to experience of
the Committee. We have filed in our office between
April 1, 1921 and April 1, 1922, twenty-five new
cases in thirteen of which suit was commenced, sev^en
of fracture and the remainder a general variety of
cases.
I am presenting to you with this report, the sta-
tistical report of our attorney, Mr. C. M. Dutcher.
In this you will discover the nature of the claims
made against doctors. Altogether 289 cases of which
194 were sued. The number of fractures being 79.
The second frequent class of claims are x-ray burns,
and the second most common is operation on the
appendix. It is interesting to note the causes which
may give rise to malpractice suits. They are of
course, somewhat numerous. Most of the cases grow
out of bad feeling which has been engendered by as
many causes as generally gives rise to disputes
among men.
We have on analyzing the cases come to various
conclusions. We have sometimes thought that it
was from ungenerous statements made by other
physicians. We sometimes thought the cause was
due to doctors attempting to collect bills which pa-
tients thought excessive or in which they did not get
the services they expected, or from harsh measures
that have been employed in collecting a bill. We
have sometimes thought that the cause was due to
the doctor not exercising proper skill. We have
sometimes thought that the cause was negligent care
on the part of the doctor.
On careful analysis of the cases from year to year,
it is found that there is no single predominating
cause. All these factors have been active one time
or another. What we have found to be true in Iowa,
has also been true in other states.
WT have had fourteen years of continuous expe-
rience, and have endeavored to give each individual
case a thorough and analytic study. WT have also
diligently inquired into the published reports of other
state societies. We find numerous references but
only one we will mention, partly from its source,
showing that no class of practitioners feel themselves
safe.
Dr. Arthur L. Chute, of Boston, in his presidential
address before the New York meeting of the Amer-
ican Urological Association says:
“There is in this countrj' at large, so far as I can
learn, an alarming increase in the number of mal-
practice suits that are being brought against physi-
cians. This condition is not due, so far as I can
determine, to physicians being less careful than here-
tofore of the interests entrusted to them but to other
changes that have taken place in the community as a
whole. I feel that our members coming from all
parts of the country as they do should take this prob-
lem up with their state medical societies, and should
see if some way can be found to lessen the annoy-
ance, financial loss, and injustice that many of these
suits have brought to medical men.”
The Cost of Medical Defense
The expense of carrying on medical defense dur-
ing the past year has been very heavy, notwith-
VoL. XII, No. 7]
Journal of Iowa State Medical Society
283
standing the fact that a part of the expense in cer-
tain cases has been borne by commercial insurance
companies.
We have paid our attorney, Mr. C. M. Dutcher,
during the past j-ear or from April 1, 1921 to April
1, 1922 as follows:
April to July, 1921 $ 533.87
July to October, 1921 1,081.47
October to January, 1922 1,085.25
January to April, 1922 1,193.42
Total $3,894.01
We have paid local attorneys as follows:
R. M. Haines, in re: Theodore Franzen vs.
Dr. L. E. Kauffman from September 24 to
30, 1921, including expenses $ 355.73
Gerrit Klay, in re: Dr. H. A. Bolstad vs.
Bert Wallings, 4 days’ trial work ending
Nov. 10, 1921 150.00
C. E. Cooper, in re: Vandervelden, vs. Dr.
W’aterhouse, Sept. 19, 1921 to 5 days’ trial,
including expenses 132.70
H. F. Barthell, in re: Theodore Franzen vs.
Dr. L. E. Kauffman, assisting C. M. Dut-
cher, Sept. 26, 27, 28 and 29, four days’ ser-
vice on said case 125.00
Livingston & Eicher, in re: Elio Noel vs. E.
T. Wickman, one trip to Iowa Cit\- to at-
tend conference with Dr. Dutcher and
others 100.00
Kindig, ^McGill, Stewart and Hatfield, in re:
Berberich vs. Dr. McHugh, Feb. 8, 1922 50.00
Dunshee & Brody, in re: Coglej- vs. Unger,
to professional service from March 7, 1921
to June 11, 1921 50.00
Molyneux, Maher and Meloy, in re: Mann
vs. Kas, to one and one-half days time in
preparation of case 37.50
Dunshee & Brody, in re: John Cogley vs. D.
Unger, to professional services in the final
settlement of the case, from September 1,
1921 to October 1, 1921 20.00
Total $1,020.93
We have practiced the closest economy possible,
considering the safety of the individual defendant.
There has been a variety of opinion expressed as to
the reason why so many claims are made against
doctors. This I think is best answered by the quota-
tion above referred to.
It may be that commercial malpractice insurance
has encouraged some of the suits on the ground of
greater certainty of collecting damages, but the rea-
son in my judgment is not so easily explained. We
believe at the present time that it is better for the
profession that we co-operated with commercial in-
surance companies, with the view of securing the
most efficient defense in malpractice suits.
W'e have certain bad years on account of a series
of cases coming to trial in rapid succession. It is
to be hoped next j'ear, there will be a smaller number
of cases coming before the committee.
STATUTE OF LIMITATIONS
We desire to call attention to the fact that the
statute of limitation in Iowa for claims of malprac-
tice runs two years, that is: if a claimant fails to file
notice of suit until after the expiration of two years
from the last treatment, he is barred from commenc-
ing suit on account of the expiration of statute of
limitation, except when the patient is a minor, then
the statute of limitation does not expire until the
patient has reached the age of twenty-one years, and
one year more. In all cases of dispute of the nature
of malpractice and a settlement is made, it must be
accomplished in accordance with certain legal pro-
cedure which our attorney will provide for.
REPORT OF MALPRACTICE CASES
During the last year, thirteen new cases have been
begun and seventeen have been disposed of. At the
date of our last report there were thirty cases pend-
ing, whereas, now there are but twenty-six.
Of the cases now pending, a large number of them
have been pending for some years, and, in our judg-
ment, will never be tried. There are five cases pend-
ing in Woodbury county, which remains the banner
county for malpractice cases.
During the year two judgments were recovered
against members of the Society, one for $6,000 and
one for $350. Motions for new trials are pending in
each of these cases, but in our opinion, the judgment
of $350 should be paid and not appealed.
Owing to the fact that a considerable number of
the defendants who have been sued during the last
year carry commercial indemnity six cases were set-
tled during the year. The particulars of the settle-
ments will be set out with the report of each case.
LIST OF CASES DISPOSED OF FROM APRIL,
1921 TO APRIL, 1922
1. This case was brought in the district court of
Decatur county in 1915, and after having assigned it
for trial many times, plaintiff finally dismissed it last
December at plaintiff’s costs. This disposition is
final.
2. This action involving a claim for .$20,000 in-
volved alleged negligence in the treatment of a frac-
ture and dislocation of the clavicle has been pending
for some years. The claim, however, has been
abandoned and the matter finally disposed of with-
out any expense to the doctor’s estate.
3. This action was pending in Woodbury county
for seven years. Nearly every term of court the
plaintiff filed a trial notice but always relented be-
fore the case was reached. It was finally dismissed
in January and is disposed of.
4. This case was dismissed by plaintiff after four
years of effort to secure some kind of a settlement.
The statute of limitations has run and the case is
ended.
284
Journal of Iowa State Medical Society
[July, 1922
5. This action was pending in the W ebster county
district court for four years and involved a claim of
$10,000 for alleged negligence in a mastoid operation.
After repeated threats to bring the case to trial, the
plaintiff finally dismissed it and the time has elapsed
for commencing it over again.
6. This action was begun in Washington county
in 1919 and involved the treatment of an injury to the
plaintiff’s hand. The case was dismissed at plain-
tiff’s costs.
7. This case promised to be of considerable im-
portance owing to a factional controversj' among the
doctors in Alason City, but it was amicably adjusted
to the satisfaction of the profession by the payment
of $50 by the Ft. Wayne company. The case is
finally disposed of.
8. This action was brought in the Jasper County
T^ist'rict Court and after three years has been dis-
missed at plaintiff’s costs and is finally disposed of.
9. This action was brought in 1920 in the District
Court of Polk County for negligence in the removal
of wax from plaintiff's ear, resulting in bloodpoison-
ing. Plaintiff was in the army at the time, and con-
siderable effort was made by us to locate the wit-
nesses. The case was set for trial once or twice
but was finally dismissed by plaintiff at his costs.
10. The defendant in this case was formerly a
practicing physician in Iowa and subsequently re-
moved to Kansas City, Missouri. W'hile a resident
of Iowa he treated a fracture of the right illium of
plaintiff and failed to discover a fracture. Deposi-
tions were taken in the case but they were of such
a nature that upon the trial of the case in the courts
of Missouri the court directed a verdict for the de-
fendant. The case is finally disposed of.
11. This action was begun in the O’Brien County
District Court for the September term, 1920. Dam-
ages in the sum of $15,000 were asked for alleged
negligence in treating a fracture of the tibia. The
patient died during the treatment. Depositions were
taken in Chicago and the plaintiff finally abandoned
the case and dismissed it at plaintiff’s costs. It is
finally disposed of.
12. This case was begun for the January term,
1921, of the District Court of Winneshiek County,
asking a judgment for $10,000 for negligence in the
treatment of a fracture of the tibia and fibula. The
case was tried in September and a verdict directed
for the defendant. Xo appeal has been taken, and
the case is finally disposed of.
13. This action was brought in Polk, county in
1921 for negligence in tying the umbilical cord of
plaintiff’s infant son, who died as a result of a hem-
orrhage. The case was set for trial and upon the
day it was reached we effected a settlement of the
case by the payment of $250. The case was a dan-
gerous one and we regard the settlement as justified.
14. This action was brought for the !March term,
1922, in the District Court of Carroll County for
$10,000 damages for alleged negligence upon the
part of the clinic in caring for plaintiff during child
birth. The defendants performed an operation and a
part of the gauze was left in the wound. It was the
judgment of the Medical Defense Committee that it
should be adjusted if possible and we regarded it as
a very dangerous case. It was settled by the pay-
ment of $700 in damages. The amount was paid by
the Ft. Wayne company which carried the indemnity.
15. This action was brought in the District Court
of Polk County for the January term, 1922. Defend-
ant operated upon plaintiff for the removal of a
cancerous formation from her breast. Plaintiff
charged that gauze used in the operation was sewed
up in the wound and negligently permitted to re-
main there, requiring several subsequent operations
and resulting in a general infection of the wound.
The result was bad and it seemed to be beyond
question that the gauze had been overlooked in the
operation. The case was settled by the Ft. Wayne
company paying $1000 upon our advice. The dam-
ages asked were $10,000.
16. This action was brought in the District Court
of Dubuque County for profesional services ren-
dered the defendants in the sum of $1363. Defend-
ants filed a counter claim charging malpractice and
asking judgment for $10,000. The malpractice, if
any, having occurred more than two years before the
filing of the claim, we took the position, after con-
ferring with the ^ledical Defense Committee, that we
were not justified in doing more than preventing the
defendants from recovering anything on their coun-
terclaim. The malpractice claimed was that in per-
forming an operation on the defendant, Emma Haf-
kemeyer, for a diseased ovary an incision was negli-
gently made into the intestine, and that she subse-
quently had to have an operation performed at
Rochester, Minnesota. We filed and submitted the
necessary pleadings to eliminate any claim for mal-
practice in excess of the amount claimed by plaintiff,
and upon the trial a verdict was for the defendants,
which meant, of course, that the defendants secured
no damages and the plaintiff failed to recover for
his services.
17. This action was brought for the January term,
1922, of the Union County IDistrict Court on a note
executed by defendant in the sum of $104.35 for
balance of professional services, defendant having
paid $300 in cash. The operation was for appendi-
citis and was performed upon the child of defendant.
Defendant counterclaimed and charged malpractice
on the part of plaintiff in leaving a part of the gauze
used in the operation in the body of the child. An
investigation of the facts showed conclusively that
the gauze was not removed hy plaintiff and that it
was an exceedingly dangerous case. Upon advice it
was settled by the cancellation of the note for $104.35
and the payment of $100 in cash.
D. S. Fairchild, Sr.,
Chairman.
VoL. XII, No. 7|
Journal of Iowa State Medical Society
285
CONDENSED REPORT OF CASES AGAINST
MEMBERS OF THE IOWA STATE MEDI-
ICAL SOCIETY, 1921-1922
To Dr. D. S. Fairchild, Dr. H. B. Jennings, and Dr.
Lewis Schooler, iMedical Defense Committee.
Gentlemen:
We have submitted a full report upon all cases
pending at the date of our last report and also of
cases commenced since that date. The following is a
summary of certain particulars in all cases com-
menced since the establishment of the Medical De-
fense Committee of the Society.
Cases commenced since organization of depart-
ment 194
Cases commenced prior to the report of 1909 15
Cases commenced during 1909-1910 13
Cases commenced during 1910-1911 10
Cases commenced during 1911-1912 14
Cases commenced during 1912-1913 13
Cases commenced during 1913-1914 10
Cases commenced during 1914-1915 24
Cases commenced during 1915-1916 19
Cases commenced during 1916-1917 17
Cases commenced during 1917-1918 13
Cases commenced during 1918-1919 14
Cases commenced during 1919-1920 7
Cases commenced during 1920-1921 12
Cases commenced during 1921-1922 13
Cases pending at date of 1909 report 7
Cases pending at date of 1910 report 10
Cases pending at date of 1911 report 14
Cases pending at date of 1912 report 25
Cases pending at date of 1913 report 26
Cases pending at date of 1914 report ; 21
Cases pending at date of 1915 report 28
Cases pending at date of 1916 report 33
Cases pending at date of 1917 report 33
Cases pending at date of 1918 report 29
Cases pending at date of 1919 report 29
Cases pending at date of 1920 report 26
Cases pending at date of 1921 report 30
Case:? now pending 26
Total cases disposed of 173
Nature of Cases
^lalpractice in removing seed wart 1
^lalpractice in not discovering and uniting sev-
ered ligaments of the wrist 1
Alleged assault 2
Removal of cancer of the hand 1
Conspiracy to have plaintiff declared insane 2
Fracture of the arm 28
Fracture of leg or femur 51
Appendicitis — sponge case 2
Caesarean operation — ^sponge case 1
Cancer in breast — sponge case J
Operating for kidney — sponge case 1
Appendicitis, malpractice in operation 5
-\ppendicitis — exploratory opening 1
Childbirth, alleged failure to attend after alleged
agreement to do so; child died (separate ac-
tion by father and mother) 2
Libel for testifying patient was insane 1
Hand crushed, alleged improper treatment 1
Failure to discover sub-caracoid dislocation of
shoulder joint 1
Hand lacerated, alleged improper treatment 1
Ear, alleged improper treatment 2
Eye, alleged improper treatment 1
Infection, childbirth 2
Medical treatment of cliild 1
Abortion, improper after-treatment 3
Abortion, without justification 2
Improper treatment of nail puncture in foot 1
Alleged removal of wrong kidney 1
Stomach trouble, alleged improper treatment and
failure to treat 1
.Vnesthetic, death under 1
Improper diagnosis of diphtheria 1
Improper dia.gnosis of broken ribs 1
Removal of uterus, alleged negligent incision of
the bladder 1
X-ray burn 6
Infection following amputation 1
.A,lleged improper treatment of scald 1
Removal of adenoids 2
Alleged improper abdominal incision 3
Failure to administer serum, patient died of lock
jaw 1
Fracture of collar bone 3
Willful insertion of instrument, producing abor-
tion 1
Operation for pregnancy of fallopian tube 1
Negligence in administration of poison, causing
death 1
Improper treatment of wound in leg from kick of
horse 1
Alleged negligence in communicating erysipelas
to woman in childbirth 1
Negligence in suffering patient mentally delin-
quent to jump out of unguarded window in
private sanitarium 1
Negligent amputation of finger 3
Negligence in attending and severing cords of
hand 1
Wrongfully administering morphine 1
Communicating small-pox to patient in hospital 1
Fracture of lower jaw 1
Dislocation of knee 1
Cancer of stomach 1
Draining pelvic abscess 1
Operation for tonsils without consent 2
Negligent incision into intestine — ovarian tumor 1
Negligence in removing button from child's
throat 1
Hot water bottle burn I
Failure to discover fractured vertebrae 1
Improper treatment of vaginal infection 2
Improper treatment of inflammatory rheumatism 2
Negligent removal of tonsils 3
Negligent treatment of gunshot wound 1
Negligent treatment of abscess of bladder 2
Negligent treatment of abscess under arm * 1
Wrong diagnosis of sprain of ankle 1
2S6
Journal of Iowa State Medical Society
[July, 1922
Failure to properly tie umbilical cord
Failure to discover fracture of ilium
Exposing patient to scarlet fever by wrong diag-
nosis
Improper treatment of insect bites
Negligent treatment of fractured finger
Improper treatment of fractured foot
Paralysis of facial nerves in mastoid operation....
Failure to diagnose abscess of kidney
Improper treatment of ligaments of wrist
Negligence in tying patient in bed, resulting in
gangrene and amputation of leg
Exploratory opening for diagnostic purposes,
negligence in exposing person, resulting in
death of child 1
Negligent burn by radium 1
Total amount of damages claimed in all
cases to date $2,028,523.00
Judgments recovered against members.... 7
-Aggregate amount ot judgments $ 15,125.00
Consultation on cases threatened in
which no proceedings were had 100
Respectfully submitted,
Dutcher & Hambrecht.
Iowa City, Iowa, May 1, 1922.
No report from Committee on Health and Public
Instruction.
No report from Committee on Eugenics.
No report from Committee on Conservation of Vi-
sion and Hearing.
No report from Committee on Legislation and
Public Policy.
REPORT OF COMMITTEE ON PUBLICATION
The report of the Committee on Publication was
given by the Chairman and Editor, Dr. D. S. Fair-
child. It was moved and duly seconded that the
report be received and placed on file. Carried.
The report follows:
The most important features in a report bj- this
Committee, have already been presented by the Sec-
retary of the State Medical Society under the head
of his own financial report which covered the earn-
ings and the expense of the Journal.
It is to be hoped that, at least, the members of the
House of Delegates have read portions of the Jour-
nal during the past year, an<l are quite capable of
judging for themselves without the assistance of the
Committee, as to its merits. The chairman of the
Board of Trustees, who makes the contracts for pub-
lishing the Journal, has reported to you the cost of
publication and the comparison with other years.
We increased the reading pages slightly last year
to find a place for some very important papers read
before the Tri-State Medical Societies of Iowa, Il-
linois and Wisconsin. In 1920, we published 430
pages and 1921, 492, which compares favorably with
the societies of other states having our population.
It is to be noted that in most states, there is more
than one journal published.
1 We are pleased to saj' to the credit of our profes-
1 sion, that we find very few Iowa contributors pre-
senting their papers to outside Journals, and it is a
1 source of considerable gratification to us that mem-
1 bers of the profession outside of Iowa seem to find
2 satisfaction in sending their papers to us for pub-
1 lication.
1 MEDICAL HISTORY
^ There is a growing interest in all the states to-
^ wards the gathering of data in relation to the early
history of medicine in the state. We had our atten-
^ tion drawn to this in 1876, when we were placed on
a committee to prepare a history of medicine in Iowa
for the centennial.
In accordance with this provision, we secured
much data from men still living that had to do with
the first physicians to locate in certain regions in
Iowa. With this data and what we have been able
to gather from various sources, we have been able
to secure a large amount of reliable data, concerning
the men that helped to develop the State of Iowa, not
onl}- advancing the cause of medicine in our own
midst, but helping to develop the common wealth in
the legislative and in other civic offices.
We have published these papers in installments in
the Journal, and have provided that it \vill all be pub-
lished in book-form when we have completed the
work. We are gratified to observe that other states
are doing the same work through committees ap-
pointed, and it is a satisfaction to us to devote a
portion of our later days in gathering material, that
might easily be lost to the profession of Iowa.
When the days of acute struggle have passed, we
find more leisure to reflect on what our profession
has done in the way of public service.
D. S. Eairchild, Sr.,
Chairman.
REPORT OF THE MEDICAL LIBRARY
COMMITTEE
The report of the Medical Library Committee pre-
pared by Mr. Johnson Brigham, State Librarian, was
read by Dr. D. S. Fairchild, Chairman of the Library
Committee. Upon motion, duly seconded, and car-
ried, the report was received.
Des Moines, Iowa, .April 5, 1922.
Dr. D. S. Fairchild,
Clinton, Iowa.
Dear Dr. Fairchild:
-Answering your request of March 27, for a report
on the condition of the Medical Library, I wish to
report as follows:
Since Miss Margaret Brinton's report in the July,
1921, issue of the Iowa State Medical Society Jour-
nal, the library has added about 500 volumes, and
the number of journals has increased from 80 to
nearly 100. I am sending you herewith a list of the
medical periodicals currently received. In addition
to these, several others are received more or less
regularly as gifts.
VoL. XII, Xo. 7]
Journal of Iowa State Medical Society
287
The number of people using the library shows a
gradual and rather satisfactory increase. During the
first three months of 1922, we loaned 337 books, as
compared with 280 for the corresponding period in
1921. During the same period 271 people visited the
library in 1922, as compared with 149 visitors in 1921.
At present there are 230 names on our list of patrons,
a considerable increase since March, 1921. There is,
of course, a proportionate increase in our correspond-
ence, as the number of out-of-town patrons increase.
The plan of keeping the late journals unbound for
several years is proving very satisfactory. It is
easier and less expensive to send out a single number
of a journal, than an entire bound volume, and at the
same time the other numbers are available for the
use of others.
We are considerably handicapped in our reference
work, by our incomplete files of periodicals, also by
the lack of a sufficient number of up-to-date books.
Even with our incomplete and inadequate resources,
the Medical Library is capable of serving a larger
number of users than are at present taking advantage
of our services. Anything that the Iowa State Med-
ical Society can do in the way of making known our
willingness to serve will be appreciated. In addition
to our own resources, we are able in many cases to
borrow from the larger libraries in Chicago and the
East.
Very truly yours,
Johnson Brigham,
Librarian.
List of Periodicals Available at the Medical Library,
Des Moines
American Journal of Anatomy.
American Journal of Diseases of Children.
American Journal of Hygiene.
American Journal of the Medical Sciences.
American Journal of Ophthalmology.
American Journal of Pharmacy.
American Journal of Physiology.
American Journal of Psychiatry.
American Journal of Public Health.
American Journal of Roentgenology.
American Journal of Surgery.
American Journal of Syphilis.
.American Medical Association Journal.
American Review of Tuberculosis.
Annals of Medical History.
Annals of Otology', Rhinology and Laryngology.
Annals of Surgery.
Archives des Maladies de I'Appareil Digestif et de la Nutrition.
Archives of Dermatology and Syphilology.
Archives of Diagnosis.
Archives of Internal Medicine.
Archives of Neurology and Psychiatry.
Archives of Pediatrics.
Archives of Surgery.
Boston Medical and Surgical Journal.
British Journal of Children’s Diseases.
British Journal of Ophthalmology.
British Journal of Surgery.
British Medical Journal.
Canadian Medical Association Journal.
Chicago Medical Recorder.
Cincinnati University Medical Bulletin.
Colorado Medicine.
Dementia Praecox Studies.
Dental Digest.
Deutsche medizinische Wochenschrift.
Deutsches Archiv fur klinische Medizin.
Endocrinology.
Heart.
Illinois Medical Journal.
Index Medicus.
Indiana State Medical Association Journal.
International Abstract of Surgery.
Iowa Dental Bulletin.
Iowa Homeopathic Journal.
Iowa State Medical Society Journal.
Johns Hopkins Hospital Bulletin.
Journal of American Institute of Homeopathy.
Journal of Bacteriology.
Journal of Biological Chemistry.
Journal of Cancer Research.
Journal of Experimental Medicine.
Journal of General Physiology.
Journal of Immunology.
Journal of Industrial Hygiene.
Journal of Infectious Diseases.
Journal of Laboratory and Clinical Medicine.
Journal of Medical Research.
Journal of Metabolic Research.
Journal of Nervous and Mental Diseases.
Journal of Organotherapy.
Journal of Orthopaedic Surgery.
Journal of Pathology and Bacteriology.
Journal of Pharmacology and Experimental Therapeutics.
Journal of Urology.
Lancet.
Medical Clinics of North America.
Medical Record.
Medical Science Abstracts and Reviews.
Medizinische Kliiiik.
Mental Hj'giene.
Military Surgeon.
Minnesota Medicine.
Missouri State Medical Association Journal.
Modern Hospital.
National Dental Association Journal.
Nebraska State Medical Journal.
New York Medical Journal.
Office International d'Hygiene.
Ophthalmic Literature.
Pennsylvania Medical Journal.
Physiological Reviews.
Public Health Nurse.
Quarterly Cumulative Index to Current Medical Litei*ature.
Quarterly Journal of Medicine.
Revue de Chirurgie.
Revue de Medecine.
Rhode Island Medical Journal
Royal Society of Medicine Proceedings.
Surgical Clinics of North America.
Surgery, Gynecology and Obstetrics.
Texas State Journal of Medicine.
U. S. Naval Medical Bulletin.
L'. S. Public Health Service.
\ irchows Archiv.
Zeitschrift fur Psychotheraoie und Medizinische Psychologic.
Announcement was made that the delegates from
the various congressional districts assemble and se-
lect a member from each district to act upon the
Nominating Committee.
Upon motion the meeting adjourned at 5:40 p. m.
The delegates from the various congressional dis-
tricts then assembled to select a member from the
respective districts to act upon the Nominating Com-
mittee.
The committee reported was:
First District — E. E. Sherman, Keosauqua.
Second District — W. P. Hutchins, Marengo.
Third District — J. C. Shellito, Independence.
Fourth District — G. A. Plummer, Cresco.
Fifth District — J. M. Young, Center Junction.
Sixth District — J. F. Herrick, Ottumwa.
Seventh District — E. B. Bush, Ames.
Eighth District — W. F. Amdor, Carbon.
Ninth District- — V. L. Treynor, Council Bluffs.
Tenth District — A. H. McCreight, Fort Dodge
Eleventh District — A. M. Bilby, Galva.
V. L. Treynor,
Chairman.
J. F. Herrick,
Secretary.
288
Journal of Iowa State JMedical Society
[July, 1922
Second Meeting — Thursday, May 11, 1922
The House of Delegates met in Room 322 Hotel
Fort Des iloines and was called to order at 8:10 a.
m. by President I’ond.
Ten officers and forty-three delegates responded
to roll call.
The reading of the minutes of the previous meet-
ing was deferred.
No report from the Committee on Legislation and
Public Policy.
No Report from Committee on Health and Public
Instruction.
No report from Committee on Eugenics.
No report from Committee on Conservation of
Vision and Hearing.
REPORT OF THE COMMITTEE ON CONSTI-
TUTION AND BY-LAWS
The report of the Committee on Constitution and
By-laws was presented by the Chairman of the Com-
mittee, Dr. V. L. Treynor. In accordance with the
provisions of the By-laws, the report was laid upon
the table.
The recommendations follow;
Chap. 4. Section 11. Adding the words “through
the Secretary” after the word present in the first
line.
By adding to Chapter 8 of the By-laws new sec-
tions as follows: Section 11. “The Committee on
Constitution and By-laws shall consist of three mem-
bers. It shall be the duties of the committee to pro-
pose such amendments to the constitution and by-
laws as is deemed wise and judicious, and to bring
before the House of Delegates such amendments as
it, or other members of the Society, may care to pre-
sent for consideration.”
Section 12. The Committee on Finance shall con-
sist of three members, whose duty it shall be to
audit the books of the Society and to make a report
of its findings to the House of Delegates.
Chapter 6. Section 3. To read as follows: “The
Treasurer shall give bond in such sum as shall be de-
termined by the Board of Trustees.”
Chapter 6. Section 3. To strike out the words,
“the sum of $20,000” (in line 1-2) and substitute the
words, “such sum as shall be determined by the
Board of Trustees,” and adding to same section the
following:
“The amount of the Treasurer's salary shall be
fixed by the House of Delegates and shall be paid
annually.”
Chapter 8. Section 8. Be amended by striking out
all words after the word “Society” in line 5, page 19
and substituting: “All bills for iMedico-Legal De-
fense, after approval by the committee and the
Board of Trustees shall be subject to warrants drawn
in the prescribed manner.”
Chapter 8. Section 9. Be repealed and the fol-
lowing substituted: “That a committee on Field
Activities be made a standing committee and that its
duties include those formerly delegated to the Health
and Public Instruction Committee and such other
duties as may be prescribed."
V. L. Treynor,
Chairman.
THE FIELD ACTIVITIES COMMITTEE
Dr. F. E. Sampson, Chairman, presented the re-
port of the Field Activities Committee which, on ac-
count of the nature of the report, and in accordance
with the by-laws was laid upon the table for one day.
The report follows:
INTRODUCTORY
In his Presidential Address one year ago, Dr.
Donald Macrae declared it was his belief that, in so
far as medical service delivered to the people of
Iowa might fall short of the highest attainable qual-
ity, such shortage was due to lack of sustainedly
functioning medical organization rather than to in-
feriority of Iowa’s doctors as individual practitioners.
He insisted that with adequate and equitably dis-
tributed institutional facilities, activation of existing
medical organizations, sustained and intelligently di-
rected co-operation between the county medical so-
cieties and other organizations and institutions of
the local communities, the counties and the state,
that Iowa would add to her list of prizes for leader-
ship, that of having not only the most adequate, but
the most equitably distributed and highest average
quality of medical service.
The unanimous and enthusiastic applause that
greeted Dr. Don’s declaration was the natural human
reaction to a high compliment.
A politician seeking personal preferment would
have stopped there. But with the insistent practi-
cality characteristic of his race, the ‘canny scot’ fol-
lowed up with a proposition that the Iowa State
iMedical Society establish the right of its members
to such high encomium, by concerted action in line
with certain recommendations set forth in the reso-
lutions which provided for the creation of the special
committee on “Field Activities.”
Before proceeding to discuss the more definite de-
tails of our report, it seems well that we call atten-
tion to a few outstanding facts that give distinction
to this action initiated by our State Medical Society.
Other state societies have talked about, and some
have actually employed a full time Secretary. So
far as I know, the American Medical Association is
the only one that has seriously considered establish-
ing Field Activities in the sense set forth in the
resolutions that created our committee and not until
the Iowa State Medical Society had delegated to a
special committee the duty of actually doing the
thing, did our American IMedical Association decide
to actually establish Field Activities, and employ a
VoL. XII, Xo.71
Journal of Iowa State Medical Society
28‘)
Field Secretary. (Ur. Olin West, who has only
within the past month taken nj) his duties.) »
The point to be impressed in the above statement,
is that your Committee has been doing pioneer work
— it had no beaten path to follow, no maps based
upon accurate surveys of the field and furthermore,
the members soon came to realize that here was not
only a new mechanism to be evolved, but that its
functioning involves an entirely new feature — almost
a new principle in medical organization, as we have
known it in the United States.
It Recognizes the County Medical Society as an
Actual Animated Entity — An aggregation of local
practitioners of medicine functioning as a local influ-
ence in local affairs and collaborating with other
local forces in definite local programs that aim to
solve problems of importance to jieople of the local
community, as well as to the local practitioners.
This in contrast with policies thus far followed by
the American Medical Association and by our State
Societies in which the central organization distrib-
uted its service to the members as individuals, and,
aside from collecting annual dues of such members,
neither demanded of, nor delivered to the county so-
ciety much, if anything, more than recognition as a
register of local members of the State SocietJ^
The object of the proposed Field Activities is to
develop our county societies as responsive and re-
sponsible medical aggregations, that shall sustainedly
function as local forces and have the collaboration
of other local agencies concerned with related ac-
tivities, and with a program adapted to the needs of
the local community.
INTERPRETATION OF THE RESOLUTIONS
By way of introduction to the definitely proposi-
tional features of our report, your committee has
found no occasion for modification of the funda-
mental law or revision of the declared purposes of
the Iowa State Medical Society.
In other words, the procedures best calculated to
serve the purposes of the proposed Field .Activities,
are not re-volutionary but ev-olutionary in character.
It is not in further multiplication of organizations
and special committees so much as in activation and
coordination of those already in existence or pro-
vided for in the Constitution and By-laws of our
state and county societies; and in effecting sustained
working relations between medical organizations and
other agencies concerned with related activities.
All the objects of the proposed field activities,
implied as well as stated, predicate upon the first,
second and third.
1. To perfect organization of county societies.
2. To stimulate activity of such societies along
public health lines.
3. To effect cooperation between county societies
and other organizations of the community.
The extent to which we accomplish the activation
of county societies, their participation in public
health activities, and their cooperation with other
agencies, will measure our progress toward the main
objective which is — to promote:
.Adequate, efficient and equitably distributed med-
ical service throughout the State of Iowa.
Since the achievement of the first and second are
pre-requisite to achieving the third, we may reduce
our proposition to the simple statement that in or-
der to successfully advance distribution and delivery
of medical service throughout the state, we must
effect cooperation between our county medical so-
cieties and other organizations and institutions oper-
ating in their respective counties.
The first step to be taken by the State Medical So-
ciety to activate its county components and effect co-
operation between them and other county organiza-
tions and institutions, would be to effect cooperation
between the State Medical Society and other state
organizations and institutions.
It is of interest to note, that your committee’s sur-
vey of the situation reveals that, the attitude of or-
.ganizations and institutions that should logically be
in a working alliance with the state and county med-
ical societies, is receptive; and, that if any consider-
able persuasion is required, it will not be in persuad-
ing the public to cooperate with us as much as in
persuading ourselves to becomingly' participate in lay
endeavors that aim to facilitate better delivery of our
own service, as a profession, and the prosperity of
Upper portion of diagram showing sources from which the
Field Activities Committee derives its members.
Cower portion of diagram showing the general plan of effecting
coordination of local county forces with the County Medical
Society as contemplated in the recommendations of the committee.
290
Journal of Iowa State Medical Society
[July, 1922
individual practitioners through increasing the actual
value of their services and educating the public to a
higher appreciation of such service.
RECOMMENDATIONS
To the President and Members of the House of
Delegates:
The Committee on Field Activities, appointed pur-
suant to Resolutions adopted by your honorable
body May 13, 1921, respectfully submits the follow-
ing recommendations.
1. That Section 9 of Chapter VIII of the By-laws
be repealed and in its stead, the following adopted:
2. That a Committee on Field Activities be made
a standing Committee, and that its duties include
those formerly delegated to the Committee on Health
and Public Instruction.
Duties
3. That in addition to the duties mentioned in
paragraph 2, it shall be the function of this Commit-
tee to collaborate with the Council as a body and
with its members in the formulation and carrying out
of programs in their respective districts. It shall be
the special agency through which the State Medical
Society and other agencies concerned with related
activities may establish sustained working relations,
formulate joint programs and promote interest and
activity in lines calculated to increase the adequacy,
efficiency, and equality of distribution of applied
medical science throughout the State of Iowa.
Number of Members and Qualifications
4. The number ot members shall be seven. With
the exception of two mentioned in paragraph 5, the
members of this Committee shall be members in
good standing in the Iowa State Medical Society.
^ Manner of Selection
(a) The President-elect shall be an ex-officio
member from his election until his inauguration as
President. The other six members shall be selected
as follows:
(b) Two shall be nominated and elected by the
Council. The other four are to be apportioned and
selected as follows:
(c) One to be chosen by the Iowa State Board of
Health.
(d) One by the Facultj' of the Iowa State Uni-
versity Medical School. (Both these to be members
in good standing of the Iowa State Medical Society.)
(e) One to be chosen by the Executive Commit-
tee of the Iowa Tuberculosis Association.
(f) One by the Executive Committee of the Iowa
State Conference of Social Work. (The two last
named may be chosen by their respective organiza-
tions for their fitness to represent the specifically
declared purposes of the organization.)
Term
6. Except the President-elect, the members of
this Committee shall be elected for two years.
(Those elected bj' the Council to cast lots for the
short term so that one of the two will be elected at
each annual meeting after 1922.)
Powers Delegated — And Limitations as to Expendi-
ture of Funds
7. The Committee on Field Activities shall be
empowered to employ such help as it deems neces-
sary within the limit of the aggregate appropriation
approved by the Board of Trustees and House of
Delegates of the State Societ}^ To enter into such
working agreements with associated agencies as it
may deem wise and proper, to recruit volunteer
speakers’ bureau and to pay the actual expenses of
such speakers, to defray also the actual expenses of
members of the Committee that are incurred in per-
formance of duties connected therewith subject to
the same rules and restrictions that apply to the
Board of Trustees. All bills for expenditure of the
appropriation shall be subject to approval of the
Board of Trustees of the Iowa State^ Medical So-
ciety after which, warrants for payment of same
shall be made according to the provisions of the
Iowa State Medical Society’s by-laws. The Commit-
tee shall not incur obligations beyond the provisions
of the appropriations placed at its disposal bj'- the
House of Delegates, but this shall not prohibit ex-
penditure of funds that may be derived otherwise
than through said appropriations.
Organization
8. The Committee shall, upon its creation under
these provisions, proceed to organize after the usual
manner. Elect a Chairman and Vice-Chairman. The
Secretar}' of the State ^ledical Society shall be made
Advisory Secretary of the Field Activities Commit-
tee.
Committee Rules
9. The Committee may make rules governing the
conduct of its affairs provided such do not conflict
with the Constitution and By-laws of the State So-
ciety. The Committee shall have power to appoint
sub-committees and to invite the (non-voting) par-
ticipation of persons as advisory members of the
Committee and in event of absence or disability of
the representative member from either the Iowa
Tuberculosis Association or the State Conference
of Social Work, the President of such organizations
may act in his stead.
Resolution for Appropriation of Funds to Carry on
the Field Activities
As part of the motion to adopt the foregoing rec-
ommendations, your Committee recommends that an
appropriation of $7,500 (seven thousand, five hundred
dollars) be provided for use of the proposed standing
Committee on Field Activities subject to conditions
set forth in paragraph 7, relating to payment of bills;
VoL. XII, No. 7|
Journal of Iowa State Medical Society
291
and that the Field Activities Committee at tlie next
annual meeting of the Iowa State Medical Society,
report on a plan lor financing the Field Activities.
Frank E. Sampson, Chairman,
iilonald Macrae, Jr.,
.\lanson M. Pond,
Field Activities Committee.
THE RESOLUTIONS
Whereas we recognize the importance of preven-
tive medicine, and
Whereas we believe in a larger measure of par-
ticipation on the part of the state and county medical
societies in public health movements.
Therefore in order to fulfill in these respects both
our desire and our recognized duty,
Be It Resolved, That it is the sense of this scien-
tific section of the State Medical Society that a di-
rector of field activities should be employed either
on full or part time.
That among his duties shall be:
1. To perfect the organization of county societies
2. To stimulate such societies to greater activity
along public health lines.
3. To effect cooperation between such societies
and other organizations in the community.
4. To cement the relationship between county
medical societies and the State Society.
5. To establish better means of communication
between the State Society and county societies.
6. To prepare proper publicity matter and to se-
cure proper publicity along public health lines and
matters of general policy and legislation; and, to
act as agent for the legislative committee of the
State Society in securing needed legislation on public
health matters and in preventing the enactment of
harmful measures.
Be It Further Resolved — That we hereby recom-
mend to the House of Delegates that at its meeting
on Friday morning. May 13, 1921, it authorize the
incoming President to appoint a special committee
having power to act in carrying out the above pur-
poses including the selection of a suitable man
either on full time or on part time and he to work
under the direction of the Committee.
It was moved and seconded that the next meeting
of the House of Delegates to be held Friday morn-
ing, May 12, be held in Room 322, Hotel Fort Des
Moines.
Meeting adjourned.
Third Meeting — Friday Morning, May 12
d'he House of Delegates met in Room 322 Hotel
Fort Des Moines and was called to order by the
IVesident at 8:07 a. m.
Ten officers and thirty-nine delegates responded
to the roll call.
.\ quorum being present, the House proceeded to
the transaction of business.
The minutes of tlnj first meeting were read, and
upon motion approved,
The minutes of the second meeting were read,
and upon motion approved.
REPORT OF THE COMMITTEE ON NOMIN-
ATIONS
The report of the Nominating Committee being
the first order of business, Dr. J. F. Herrick, Secre-
tary of the Committee, presented the report.
The report follows:
For President-Elect — Dr. Frank M. Fuller, Keo-
kuk; Dr. S. Spilman, Ottumwa; Dr. O. J. Fay,
Des Moines.
For First \'ice-President— Dr. George Kessel,
Cresco.
For Second \'ice-l’residcnt — Dr. O. F. Parish,
Grinnell.
For member Board of Trustees — Dr, H. C. Esch-
bach, Albia.
For Delegates to A. M. — Dr. L. \V. Dean, Iowa
City; Dr. Wm. L. Allen, Davenport.
For Alternate Delegates to A. M. A. — Dr. D. N.
Loose, Maquoketa; Dr. B. L. Eiker, Leon.
For Medico-Legal Committee — Dr. H. B. Jennings,
Council Bluffs.
For Constitution and By-laws Committee — Dr. V.
L. Treynor, Council Bluffs; Dr. C. B. Taylor, Ot-
tumwa; Dr. Tom B. Throckmorton, Des Moines.
For Public Policy and Legislation — Dr. W. W.
Pearson, Des ^loines; Dr. B. L. Eiker, Leon; Dr. D.
J. Glomset, Des Moines.
For Publication Committee — Dr. D. S. Fairchild,
Clinton; Dr. W. L. Bierring, Des Moines; Dr. C. P.
Howard, Iowa City.
For Finance Committee — Dr. C. P. Frantz, Bur-
lington; Dr. A. E. King, Blockton; Dr. E. C. Mc-
Clure, Bussey.
For Medical I.ibrary Committee — Dr. D. S. Fair-
child, Clinton; Dr. W. L. Bierring, Des Moines; Dr.
O. J. Fay, Des Moines; Dr. Gershom H. Hill, Des
Moines; Dr. George Royal, Des Moines.
For Councilor, Second District — Dr. David N.
Loose, Maquoketa.
For Councilor, Ninth District — Dr. H. B. Jennings,
Council Bluffs.
Dr. F. M. Fuller, asked that his name be with-
drawn as he, being a member of the House of Dele-
gates, was not eligible.
Dr. H. C. Eschbach, asked that his name be with-
drawn as a candidate for the Board of Trustees.
Dr. Tom B. Throckmorton, Secretary, presented
the resignation received from Dr. L. W. Dean, as
Delegate to the M. A.
Motion was made that the House of Delegates
take a recess of five minutes to allow the Nominat-
ing Committee to fill the vacancies in the list of of-
ficers and delegates. Seconded.
Motion was made by Dr. Conkling, seconded by
Dr. Voldeng that the House proceed with the trans-
action of business. Dr. L. Treynor rose to a
292
Journal of Iowa State IMedical Society [July, 1922
point of order that the report of the Nominating
Committee must be the first order of business.
The President sustained the point of order made
by Dr. Treynor; and the motion before the House
was put and carried.
The House reconvened and the report of the Nom-
inating Committee on \'acancies was made as fol-
lows:
President-Elect — Dr. A\'. A. Rohlf, Waverly.
Member Board of Trustees — Dr. T. W. Cokenower,
Des Moines.
Delegate to A. M. A. — Dr. Donald Alacrae, Jr.,
Council Bluffs.
Medical Library Committee — Dr. C. E. Holloway,
Des ^loines.
It was moved and seconded that the report of the
Nominating Committee be accepted.
Motion carried.
Election of Officers
The House proceeded to an election.
The President appointed Dr. W. B. Small, Water-
loo and Dr. il. N. Voldeng, Woodward, to act as
tellers.
The ballot was taken for President-Elect.
Eorty-six ballots were cast. Dr. Oliver J. Fay, of
Des Moines, having received the majority of the
votes cast on the first ballot, was declared elected
President-Elect, by President Pond.
Dr. Treynor moved that the election of Dr. Fay be
made unanimous. Seconded and unanimously car-
ried.
Dr. T. F. Herrick moved that, as there was but one
candidate for the other offices, the Secretary be
authorized to cast the vote of the House of Dele-
gates for the remaining officers and committees.
Seconded and carried.
I'hc Secretary then declared the ballot so cast.
An invitation for the next annual session of the
Iowa State Medical Society to be held in Ottumwa
in 1923 was extended.
Motion was made and duly seconded that the invi-
tation to meet in Clttumwa be accepted. The date
to be May 9, 10, 11, 1923.
^lotion carried.
Report was sent by the Chairman of the Legisla-
tive Committee, Dr. \\ . \\ . Pearson, Des Moines,
that on account of there having been no session of
the legislature the past year, there was nothing to
report.
REPORT OF THE COMMITTEE ON HEALTH
AND PUBLIC INSTRUCTION
The report of the Committee on Health and Pub-
lic Instruction was made by Dr. Jeannette F. Throck-
morton, Chariton.
It was moved and seconded that the report be ac-
cepted. Carried.
The report follows:
During the past year as state lecturer for women,
she has given over r>00 lectures reaching 97,500 girls
and women in 137 cities and towns of the state, and
requiring 394 speaking hours.
These lectures were given to high school girls,
college women, women’s clubs and women in indus-
try and business. There is great demand for, and
tremendous possibilities in this educational phase of
public health, and thinking men and women are
deeply interested in it. May it be stated as an index
of this interest, that there are still over thirty
towns on her waiting list, some of which want a
week.
It is gratifying to recall that the Iowa State Med-
ical Society sagaciously discerned the need of such
work some ten years ago, and in those distant day--
formed this Committee on “Health and Public In-
struction,’’ on which it has been her pleasure to serve
ever since. She thanks you for this privilege.
Respectfully submitted,
Jeannette F. Throckmorton.
No report from Committee on Eugenics.
REPORT OF COAIMITTEE ON CONSTITU-
TION AND BY-LAWS
The report of the Committee on Constitution and
By-laws w^as given by the Chairman, Dr. V. L. Trey-
nor, Council Bluffs. The Committee recommend
the adoption of the amendments.
The report follows:
Chapter 4. Section 11. Adding the words “through
the Secretary’’ after the word present in the first
line.
By adding to Chapter 8 of the By-laws new sec-
tions as follows: Section 11. “The Committee on
Constitution and By-laws shall consist of three mem-
bers. It shall be the duties of the committee to pro-
pose such amendments to the constitution and by-
law's as is deemed wise and judicious, and to bring
before the House of Delegates such amendments as
it, or other members of the Society, may care to pre-
sent for consideration.’’
Section 12. The Committee on Finance shall con-
sist of three members, whose duty it shall be to
audit the books of the Society and to make a report
of its findings to the House of Delegates.
Chapter 6. Section 3. To read as follows: “The
Treasurer shall give bond in such sum as shall be
determined by the Board of Trustees.’’
Chapter 6. Section 3. To strike out the words,
“the sum of $20,000’’ (in line 1-2) and substitute the
words, “such sum as shall be determined by the
Board of Trustees,’’ and adding to same section the
following:
“The amount of the Treasurer’s salary shall be
fixed by the House of Delegates and shall be paid
annually.’’
Chapter 8. Section 8. Be amended by striking out
all words after the word Society in Line 5, Page 19
and substituting: “All bills for iledico-Legal De-
fense, after approval by the committee and the Board
of Trustees shall be subject to warrants drawn in the
prescribed manner.”
VoL. XII, Xo. 7j
Journal of Iowa State Medical Society
293
Chapter 8. Section 9. 1)C repealed and the fol-
lowing substituted: “That a committee on Field
Activities be made a standing committee and that
its duties include those formerly delegated to the
Health and Public Instruction Committee and such
other duties as may be prescribed.”
L. Treynor,
Chairman.
On several motions, duly seconded and carried,
each amendment was adopted; and on motion, dul\
seconded and carried, the report as a whole was
adopted.
REPORT OF THE FINANCE COMMITTEE
The report of the Finance Committee was pre-
sented by Dr. E. C. McClure, Bussey, member of
the Committee, who moved its acceptance.
On motion, duly seconded and carried, the report
was adopted.
The report follows:
Your Committee on Finance has the honor to re-
port to you the condition of your finances and to
say that we have carefully checked over the books
and statements of the Secretary and Treasurer in
so far as they pertain to the financial affairs of the
Society.
We find that the records have been carefully and
sj-stematically kept, showing vouchers, checks, bills,
banking deposits, etc., which check up accurately, to-
gether with a showing of certain assets of the So-
ciety consisting of Liberty and school bonds.
We find that the balance sheet shows as follows:
Balance on hand April 30, 1921....$32,225.44
Received from Secretary 19,170.35
School bonds ($2000) purchased
for 1,909.16
Interest on $20,000 Liberty
Bonds 850.00
Interest on School Bonds 50.00
Interest on Deposits 219.23
Total Receipts $54,424.18
Expended as per evidence $19,871.81
Less check not yet cashed 550.50 19,321.31
Assets
Liberty Bonds $10,000.00
Liberty Bonds 8,600.00
Morris Bank acceptance paper 2,002.96
School bonds ($2000) , 1,909.16
Time deposits People’s Sav. Bk. 10,734.70
Checking account People’s Sav-
ings Bank 1,856.05
Total on hand Apr. 30, 1922 ^ $35,102.87
$54,424.18
Respectfully submitted,
Chas. P. Frantz,
Chairman.
REPORT OF THE FIELD ACTIVITIES
COMMITTEE
The report of the Field Activities Committee pre-
sented at the Thursday meeting and laid upon the
table, was read by the Chairman of the Committee,
Dr. F. E. Sampson, Creston.
Dr. A. M. Pond, President, and member of the
Committee, gave a summary of the work of this
Committee in its endeavor to secure the very best
information and guidance possible to perfect the
recommendations incorporated in the Committee’s
report which is now before the House of Delegates.
The report and the remarks of the President were
received with applause.
Dr. C. E. Boice, Washington, moved the adoption
of the' report, which was seconded by Dr. H. C.
Eschbach, Albia.
After some discussion on various phases of the
report, the motion was put and carried unanimously.
(See page 288 for report.)
Dr. V. L. Treynor, Chairman of the Committee on
Constitution and By-laws explained that as the Re-
port and Resolution carried a change in the Consti-
tution and By-laws relative to certain committees,
and had been accepted, no further action was re-
quired.
Dr. V. L. Treynor moved that the delegates of the
Iowa State Medical Society to the American Medi-
cal Association be instructed to make a report, at
the next meeting of the House of Delegates, of the
matters in which they participated. Seconded and
carried.
Dr. F. E. Sampson moved that the Field Activities
Committee now’ e.xisting be continued in its function
until the formation of the new committee and matters
be taken over from the present committee. Sec-
onded and carried.
NEW BUSINESS
Dr. Tom B. Throckmorton, Secretary, presented
the following communication from the secretary of
the Nebraska State iMedical Society:
Omaha, Nebr., April 29, 1922.
Tom B. Throckmorton, M.D.,
Iowa State Medical Society,
Des Moines, Iowa.
Dear Doctor:
.-Lt the meeting of the House of Delegates of the
Nebraska State Medical Association, I was instructed
to confer with you to get your opinion as to the ad-
visability of a joint meeting of the Nebraska State
Medical Association and the low’a State Medical So-
294
[July, 1922
Journal of Iowa State IMedical Socif:ty
ciety in 1924. Dr. iSIacrae of Council Bluffs and Dr.
Overgaard of (!)niaha were the originators of this
idea.
If j ou think it is at all practicable, may I ask you
to bring it up to your House of Delegates at the com-
ing meeting and get their action on it? It was sug-
gested that this meeting be held in Omaha, as it is
probably the most central point for both states. If
necessary, your House of Delegates could meet in
Council Bluffs, and the general sessions meet in
Omaha.
Fraternally yours,
R. B. Adams, Sec’y.,
Nebraska State !Med. Ass’n.
Dr. V. L. Treynor; “I have had considerable dis-
cussion with members of the State iMedical^ Society
of Nebraska relative to holding a joint meeting with
Iowa and I have discouraged it as ours is largely a
business organization, and it seems to me that it
would not be at all feasible to hold a meeting of that
character. We might hold our business sessions and
then adjourn to meet for one day. We can accept
their invitation to meet in this way.”
Fourth District — Paul E. Gardner. Chairman l'J2i
Fifth District — George E. Crawford, Cedar Rapids 192.3
Si.vth District — O. F. Parish, Grinnell 1923
Seventh District — Channing G. Smith, Granger 1921
Eighth District — Samuel Bailey, Mount Ayr 1924
Ninth District — H, B. Jennings, Council Bluffs 1927
Tenth District — \\ . W, Beam, Rolfe 192'i
Eleventh District — G. C. Moorehead, Ida Grove 1925
TRUSTEES
J. \V. Cokenower, Des Moines 1925
W . B. Small. Waterloo 1924
T. E. Powers. Clarinda 1923
DELEGATES TO A. M. A.
Donald Macrae. Tr.. Council Bluffs — 1924
\V. L. Allen. Davenport 1924
J. C. Rockafellow, Des Moines 1923
ALTERNATE DELEGATES
D. N. Loose, Maquoketa
B. L. Eiker. Leon
M. N. Voldeng, Woodward
COMMITTEES
Medico-Legal
1). S. Fairchild. Sr., Clinton
Lewis Schooler, Des Moines
H. B. Jennings, Council Bluffs
It was moved and seconded that we accept the in-
vitation to hold a joint meeting as outlined by Dr.
Treynor. Motion carried.
Dr. T. B. Throckmorton presented the following
amendment to the by-laws; that the President-elect
shall be Chairman ex-officio of the House of Dele-
gates, and moved its adoption.
Motion was made, duly seconded and carried that
the amendment be referred to the Committee on
Constitution and By-laws.
Upon motion, the House adjourned at 10:00 a. m.
Tom B. Throckmorton,
Secretary.
MEETING OF THE COUNCIL
A meeting of the Council of the Iowa State Medi-
cal Society followed the adjournment of the House
of Delegates May 12, 1922. Dr. Paul E. Gardner.
New Hampton, was reelected Chairman and Dr. A.
G. Shellito, Independence, relected Secretar\-.
Paul E. Gardner.
Chairman.
IOWA STATE MEDICAL SOCIETY OFFICERS
AND COMMITTEES 1922-1923
President. Charles J. Saunders, Fort Dodge
President-Elect - Oliver J. Fay, Des Moines
First Vice-President George Kessel, Creseo
Second Vice-President O. F. Parish. Grinnell
Secretary Tom B. Throckmorton, Des Moines
Treasurer Thos. F. Duhigg, Des Moines
Editor David S. Fairchild. Sr., Clinton
COUNCILORS _ _ .
Term Expires
First District — R. S. Reimers, Ft. Madison 1925
Second District — D. N. Loose. Maquoketa .1927
Third District — .^. G. Shellito, Independence, Secretary 1926
Scientific W ork
Chas. J. Saunders Fort Dodge
Tom B. Throckmorton Des Moines
Thos. F. Duhigg Des Moines
Public Policy and Legislation
W. W. Pearson Des Moines
B. L. Eiker Leon
D. J. Glomset .... Des Moines
Chas. J. Saunders. Fort Dodge
Tom B. Throckmorton Des Moines
Constitution and By-Laws
V. L. Treynor Council Bluffs
C. B. Taylor .Ottumwa
Tom B. Throckmorton Des Moines
Publication
D. S. Fairchild, Sr Clinton
W. L. Bierring — Des Moines
C. P. Howard Io"a City
Finance
C. P. Frantz . Burlington
A. E. King Blockton
E. C. McClure Bussey
Arrangements
Chas. T- Saunders - Fort Dodge
Tom B. Throckmorton Des Moines
Thos. F. Duhigg Des Moines
T. F. Herrick... Ottumwa
C. B. Taylor . . Ottumwa
Medical Library
D. S. Fairchild. Sr.. - Clinton
W. L. Bierring Des Moines
O. J. Fay Des Moines
G. H. Hill Des Moines
C. E. Holloway Des Moines
Field Activities Committee
Iowa State Med. Society President-Elect O. J. Fay, Des Moines
Iowa State Medical Society B. L. Eiker, Leon
Iowa State Medical Society W, L. Bierring, Des Moines
Iowa State Board of Health R. P. Fagan, Des iloines
Facultv State University Med. College N. G. Alcock, Iowa City
State Conference of Social Work F. E. Sampson. Creston
Iowa Tuberculosis Association... T. F. Edmonds, Des Moines
VoL. XII, No. 7]
JouRXAL OF Iowa State Medical Society
205
HOSPITAL STANDARDIZATION FROM THE
VIEWPOINT OF THE HOSPITAL
* TRUSTEES
I come to speak to you not from the standpoint of
a trustee of a hospital but from the standpoint of the
executive secretary of the Board of Hospitals and
Homes of the Methodist Church which during the
past year has had for its distinct service the program
of standardizing its hospitals, making a survey of
all the institutions within the bounds of the board
and seeking to find out the exact facts in relation to
all of the work in our various institutions, especially
of the church with which I am affiliated.
Up until a year and one-half ago, the hospitals
operating under the Methodist Episcopal Church had
no connection whatever one with the other. We had
no board. Since that time a board has been or-
ganized, and the very first question that came before
us for consideration was: “What standard shall we
adopt and put into effect in regard to our hospital
work?” There was only one answer to that — the
minimum standard adopted by the American College
of Surgeons. That is the best there is at the present
time. Whenever we do see a better plan than that
adopted by the American College of Surgeons, wc
shall add that to our already adopted program.
Boards of Trustees
In making a survey of our hospitals during the
past year, sixty-five operating institutions, we have
to begin back with the board of trustees, and we find
some very interesting facts in our survey. Now,
there are four kinds of boards of trustees, inasmuch
as there are*state institutions, municipal institutions,
private institutions, memorial in character more or
less, and also institutions operating within the
bounds of some one of the denominations. So we
have practically four kinds of boards of trustees. The
state hospitals deal with their trustees through their
state-appointed officers and trustees; the municipal
hospitals, through officers and trustees appointed by
the municipality; and the private hospitals are
largely run by physicians with particular objectives
in mind, memorial hospitals being private hospitals
which have been built as memorials for families or
for a group of people. We have different objectives
in each group.
Now I will take up our own church hospitals.
For instance, in an organized society, we have a
body of men, the laity and missionary people, who
want a hospital and want the church to get back of
it. The important objective of any of these hospitals
is the same, that is, that the patients shall have the
very best kind of service rendered to them, from the
diagnostic standpoint, the standpoint of treatment,
or whatever it may be.
When we come to the standardization program,
one of the first things that we find is that we have
to standardize a lot of boards of trustees. There
are as many and varied kinds of ideas among boards
of trustees as to what is the standardization program
of the .-Kmcrican College of Surgeons as there are
among some other classes of folks who are non-
medical practitioners. And we ha\ e had some very
interesting sessions with men who for years have
been president and secretary and treasurer of boards
which have had very little to do with the hospital
program. We have had this question asked man\
times: “Who are you? What does this mean any-
way?” Most of them think it means expenditures of
money, and it does. But without e.x])cnditures of
monej% we can never get to any place in the world.
And I have been very frank to say to these members
of our trustees: “You have run the institution on a
cheap plan and you will have a cheap result.” It
means that you will have to expend more money and
the best results cannot be secured without putting
into it an adequate amount of money. And the
boards of trustees of many of our institutions are
very unconscious of the fact that none of our insti-
tutions can turn out the best product unless they
provide conditions which are favorable.
Co-operation of Trustees and Staff
So we face this problem. Many of our trustees
have never been in close contact with the staff. They
do not know what the staff wants to do. They do
not know what a case record looks like. It is abso-
lutely unreadable to them. And so you must edu-
cate the board of trustees to know what a really
readable chart is and what kind of an analysis should
be made in order that patients should have the very
best means of diagnosis and the very best service
rendered them.
Financial Interests
Another feature directly concerns the board of
trustees. They are tremendously interested in the
financial interests of the hospital. I know one in-
stance where a board of trustees had notes at the
bank amounting to fifty-five or si.xty thousand dol-
lars, they were running behind in their current ex-
penses, they did not know just how to meet them, or
where they were going to get the money to buy all
the equipment that the hospital was calling for. The
proposition came up of a new staff organization in
the hospital, which would entail the expenditure of
an additional amount of money. Could they afford
to add additional expense to the already great bur-
dens in order to establish a standardized staff? And
in organizing that standard staff, the plan was to de-
termine and specialize the entire staff development.
And the president of the board of trustees said
frankly, after he had been in close contact with the
chief of staff: “We cannot afford not to put in the
additional equipment, to put in all the standard re-
quirements, regardless of the extra expenditure of
money that it does entail!”
-■\nother instance: here is a hospital with a board
of trustees which during the past years has not been
making any reports to anybody. They have not
been responsible to anybody. This board of trustees
has been a unit in itself as a hospital, not making a
296
Journal of Iowa State ^Medical Society
[July, 1922
report to any city or state. But somebody else
comes along — the American College of Surgeons —
and says to the surgeons of the staff: “You do not
meet the requirements.” A man from the outside
steps in and says: “Can we see your hospital rec-
ords? Can we examine your laboratories and equip-
ment and see what you are doing?” If the surgeons
and physicians in 3'our communitj' are to be held re-
sponsible for the results of their services in the in-
stitution, then the responsibility- for that must come
back to the board of trustees and also to the people
outside who furnish the money to keep the institu-
tion going.
Laymen Pleased with Program
We started in to adopt the whole program and the
result has been that the boards of trustees are doing
their duty toward their institutions and toward the
community; whereas a year and a half ago they were
letting the staff attend to responsibilities; today they
have a larger view of their problem, and a more in-
telligent appreciation of the work that the institution
is trying to do for the citj% the state, and the church.
There is one more word I want to bring to you.
I believe that the body of laymen throughout the
entire country are tremendously pleased with this
great program. Why should they not be? As busi-
ness men asking for the best results, they could do
no better than adopt the program of the American
College of Surgeons. A man can only sell something
if he has it to sell. He cannot sell what he does not
have in the shop. So the doctor who say^s, “I can do
certain things,” but cannot produce the goods does
not last very long. We have had some non-medical
practitioners who have said: “We will close your
doors unless we can bring in our patients, regardless
of your rules and regulations.” The state can hold
the board of trustees responsible to the state. They'
have not gone that far yet. But the state has a re-
sponsibility' as to what the board of trustees does,
and the responsibility' for every case that comes into
the hospital comes back to the trustees in the end
If that is so, then the other truth is self-evident that
no board of trustees can allow practitioners to come
into the hospital who cannot give proper diagnosis
or proper treatment or do proper service. They-
must meet the requirements. And I am sure I speak
this morning for a very large number of people and
a large number of institutions, and I am very glad,
indeed, that the doctors of the American College of
Surgeons have made up this program during the past
three or four y'ears and have established a standard.
Dr. Martin has been the life saver for hundreds of
physicians.
In closing, so far as our own institutions are con-
cerned, we intend to stand by this program and see
that it is put into effect. — Xewton E. Davis, D.D ,
Chicago, Executive-Secretary, Conference Board of
Hospitals and Homes of the ^lethodist Church.
MEDICAL NEWS NOTES
At a meeting held April 25, 1922, the Polk County-
Medical Society decided to hold a three-day clinic
some time in October, 1922. By co-operation among
members of the society and the five excellent hospi-
tals here it is believed that the undertaking will be a
great success.
The territory adjacent to Des Moines includes a
population of approximately a half million, from
which an abundance of clinical material is available.
The five excellently equipped hospitals will fur-
nish the facilities for demonstrating the cases. There
is an abundance of professional skill, making all the
requisites for a successful clinic. With the organiz-
ing skill to coordinate all these in harmonious ac-
tion the clinic in October will be one of the big
events, of the state in the medical field.
The following committees were appointed to ar-
range the details:
Program Committee: Dr. A. P. Stoner, president
Polk County iMedical Society; Dr. James Taggart
Priestley, president of the staff, Mercy Hospital; Dr.
A. C. Page, president of the staff, ^lethodist Hospi-
tal; Dr. W. S. Conkling, president of the staff,
Lutheran Hospital; Dr. W. L. Bierring, president of
the staff, Samaritan Hospital; Dr. E. G. Linn, presi-
dent of the staff. Congregational Hospital.
Arrangements Committee: Doctors F. R. Hol-
brook, ^I. L. Turner and Ralph H. Parker.
Publicity Committee: Doctors Thomas F. Du-
higg, W. E. Sanders and D. T. Glomset.
At a meeting May 13th the various committees
appointed to arrange for the clinics to be held in Des
^Moines in October, set the definite dates of October
17, 18, 19, 1922.
These clinics will be held at the following hospi-
tals; Mercy Hospital, IMethodist Hospital, Congrega-
tional Hospital, Lutheran Hospital, and Samaritan
Hospital. They will be conducted by members of
the profession and of the Polk County- ^Medical So-
ciety. The headquarters for the meeting will be the
Hotel Fort Des Moines. Social entertainment will
be provided at the evening sessions.
At least two out of town physicians of national
repute will be on the program.
The clinics will be held simultanously at each hos-
pital between the hours of 8 to 5 each day. They will
embrace the following departments; general surgery,
internal medicine, diseases of the eye, diseases of the
ear, nose and throat, nervous and mental diseases,
x-ray, genito-urinary, dermatology, gynecology, bone
surgery, gastrointestinal diseases, diseases of the
chest, orthopedic-surgery, the general subject of
therapeutics, pediatrics, laboratory demonstrations
and diagnostic methods.
No effort will be spared to make the clinics the
best possible. The program will contain material ot
interest to those engaged in every department of the
practice of medicine, whether specialists or general
practitioners. We hope that every physician in the
VoL. XII, Xo. 7]
Journal of Iowa State Medical Society
207
state will mark the dates October 17, 18, 19, 1922,
and arrange his work to make attendance possible
during the three days. This will prove beneficial to
every doctor who attends. Every effort will be made
to make the clinics instructive, to make your quarters
comfortable and your spare time enjoyable.
Dr. J. B. Blything, for the past two years city
physician, Davenport, was reappointed by the board
of health. The appointment will be confirmed at
the meeting of the city council.
Dr. Blything was appointed to the position of cit\
physician by the Barewald administration two years
ago.
The board of health led by jNIayor Mueller, de-
clared war on unclean and unsanitary garbage cans.
The board decided to appoint an assistant to the
health officer whose duty will be to see that the
garbage laws are not violated. The appointment of
the assistant will be made later.
The city papers, as well as their rural contem-
poraries, get things wrong occasionally. Recently
the Des ^Moines Register announced that the next
meeting of the State Medical Society would be held
here. In fact it is to be held somewhere else, but
Doctor Fellows suggests that the mistake in the an-
nouncement ought to put Algona wise to the situa-
tion that exists here when it comes to entertaining
large conventions. We have no place to feed and
sleep a thousand delegates — unless we send them
out to the Country Club and let them make their
beds under the stars! — Algona Advance.
Plans for the organization of four nursing groups
to form a part of the disaster relief unit of the Polk
County Red Cross were formulated at a meeting
held May 15 in Hotel Savery.
T. J. Edmonds, chairman of the unit of the Polk
County Chapter, talked on “Disaster Relief.”
Red Cross nurses are asked to read carefully and
decide upon which of the following units they can
best serve. In order that approximately the same
number of nurses may be in each group, which is
composed of ten, one may indicate another group in
which they might serve if the one they choose has
too many enrollments. Nurses are asked to fill out
slips and mail to the chairman, Anna Drake, 518 Cen-
tury building, Des Moines, Iowa.
The following units are offered:
Unit. 1. Emergency unit. Might serve for one
day or parts of several days in Des Moines in a dis-
aster where first aid is needed. Might included mar-
ried nurses and those holding executive positions
such as superintendent of hospital or training school
who might leave their work for one day.
Unit 2. For temporary work covering a few days.
These might be public health nurses or those whose
associations might loan them to the Red Cross for a
few days without disrupting their regular work.
Unit 3. For continued duty covering a week or
more (probably on pay). This might cover a serious
disaster in Des iMoines or in the state, or might
mean responding to a call outside the state.
Unit 4. Reserves. For substitutes or in cases of
e.xtreme need. This group would include nurses who
are tied down by home cares or who are in positions
not easy to leave, but who would be willing to make
arrangements to serve in case of extreme need.
The proposal of the ^larshall County Medical So-
ciety to assume charge of medical care of the county
poor and of patients who now are sent to the intern
hospital for treatment, with the object of reducing
the cost to the county, came before the county board
of supervisors, when Supervisor J. L. Wylie offered
a resolution providing for the acceptance of the pro-
posal. The resolution, if passed, would abolish the
offices of matron and physician of the intern hospital.
The resolution, as presented, offered no stipulated
sum as payment to the medical society for its work,
leaving the question of remuneration to be de-
termined later by the board and the society. The
resolution was presented at a meeting of the board
in committee and will la^- over until a regular ses-
sion.
The resolution, as offered by Wylie, was as fol-
lows :
“That the medical association of Marshall county
be employed to furnish treatment and medical aid to
the poor of Marshall county, not including the county
home, at a yearly compensation to be agreed upoh
between the medical association of IMarshall county
and Marshall county (through its board of super-
visors), said compensation to be paid monthly, and
further that as soon as said employment is accepted
by the medical association of ^Marshall county, the
operation of the county intern hospital be discon-
tinued and the employment of the matron and physi-
cian be dispensed with.”
Dr. J. F. Herrick, prominent local surgeon and
physician and a major with Hospital Unit R in
France during the World War, is the president of
the newly organized Military Surgeons Club of Iowa
This club, just formed at Des Moines, approved
plans for the building of a memorial hospital at
Camp Dodge in honor of the doctors, nurses and
enlisted men of the medical service who lost their
lives during the war. Dr. C. B. Taylor of Ottumwa
is a member of the committee of three in charge of
the hospital.
Plans call for the erection of a $40,000 structure
which will be started as soon as the money is avail-
able. Funds probably will be raised by popular sub-
scription. The hospital would be used during camp
periods of national guards and by the general public
in time of disaster or epidemic.
This matter was brought before the members of
the Wapello County Medical Association by Capt.
H. W. Sellers and other national guard medical of-
ficers a few months ago and endorsed. Similar ac-
298
Journal of Iowa State Medical Society
[July, 1922
tion has been taken in all parts of the state. The
committee in charge has Dr. W. S. Conkling of Des
Moines as chairman. Drs. Taylor of Ottumwa and
Earl B. Bush of Ames, other members. Dr. Con-
kling is the vice-president of this new Military Sur-
geons’ Club of Iowa, of which Dr. Herrick is the
head and Dr. A. L. Downing of Des Moines is the
secretary. Members of the board of trustees are
Drs. A. S. Price of Des Moines, A. H. J^IcCreight of
Ft. Dodge and D. L. Glomset of Des Moines.
Dear Doctor Fairchild:
I thought perhaps it might interest you and your
readers to know that on Thursday evening at the
last state medical meeting, there was a compli-
mentary dinner given Dr. F. \\’. Dean by his former
interns. There were twenty-one of the men present.
A fine token was presented Dr. Dean, in the form
of a Hamilton watch. This was the first gathering
of the Dean men and they were organized electing
Dr. G. H. Harkness, Davenport, president and Dr.
C. H. Fauder, Grinnell, secretary.
Edwin Cobb.
SOCIETY PROCEEDINGS
Clinton County Medical Society
The May meeting of the Clinton County Medical
Society was held on the evening of the 18th, at the
Fafavette Hotel, Clinton, Iowa, with a large attend-
ance of members present.
After a dinner, served at six-thirty, a short busi-
ness session was held, followed by an address by
Dr. A. W. Blunt of Clinton, on Some Problems in
Pregnancy and the Puerperium.
The subject was presented in a most able manner,
and the discussion following was participated in by
all members present.
The meeting was undoubtedly one of the most
instructive and valuable ever held by the local so-
ciety. S. Jordan, Sec’y.
Fremont County Medical Society
The Fremont County Medical Society was enter-
tained Tune 22 by Dr. William Kerr of Randolph, the
occasion being the twentieth anniversary of the
doctor’s practice at Randolph. A seven o’clock din-
ner was served to eighteen physicians including
guests from Council Bluffs. Scientific papers as
follows were presented: Donald Macrae, Jr., Diag-
nosis of Gastric Ulcer; V. L. Treynor, Manifestations
of Pain in Some Forms of Syphilis; A. A. Johnson,
Importance of Carefulness in Making Diagnoses;
C. A. Hill, Some Observations; all of Council Bluffs.
Dr. H. J. Piper of Randolph for many years presi-
dent of the Society, also addressed the doctors. A
unanimous expression of appreciation was tendered
Dr. Kerr for his hospitality. The next meeting of
the society will be held at Tabor in September.
A. E. W.
Jackson County Medical Society
Spring meeting held in Maquoketa, May 31, 1922.
Meeting called to order by President R. H. Lott.
In addition to members, there were in attendance
Dr. Sharp from the Dentists’ Club, and Nurse Wen-
dell, secretary of the Jackson County Public Health
Association. Motion carried to hold a joint picnic
meeting on June 22 with the Jackson County Public
Health Association and Dentists’ Club.
Recognizing the good work the Red Cross Nurse
has done during the past year, a committee was ap-
pointed to petition the board of supervisors to ap-
propriate funds and employ a county nurse for the
coming school year.
Dr. Frank gave clinical report of case of empyema
with x-ray demonstration. Also two cases of osteo-
sarcoma with x-ray plates. Dr. E. M. Medlar, of the
State University gave a paper, with lantern slides on
Relation of Chronic Mastitis to Carcinoma of
Breast. Sections from same breast showed degener-
ation of tissue from mastitis to malignancy.
Drs. Griffin and Lowder were appointed a com-
mittee to outline plan under which the society can
bid for contract with the board of supervisors to
render medical aid to the indigent poor of Jackson
county during next year. Said committee to report
at the fall meeting.
D. N. Loose, Sec’y.
Lee County Medical Society
A semi-annual meeting of the Lee County Medical
Society was held in Keokuk, Maj' 4. Before a dinner
in the private dining room at the Y. W. C. A., at-
tended by about twenty-five doctors, the following
program was given:
Paper on Penetrating Wounds of Eye, with His-
tory of Cases — Dr. F. Chapman.
Paper on Rectal Examinations — Dr. F. W. Noble.
Industrial Surgery — Dr. J. E. Chalmers.
Treatise on Gastric Ulcer — Dr. William Hogle.
An orchestra furnished music during the dinner
and six nurses and two sisters were present during
the program. The following out of town doctors at-
tended the dinner: Drs. Wahrer, Chalmers, Rea,
Kassen, Newlon, Newton, Travers, Bess, Grimwool
and Noble from Fort Madison, and Dr. Saar from
Donnellson.
The next meeting will be held in Fort Madison,
December 28, of this year.
Drs. Fuller, Clark and Armentrout were in charge
of arrangements, and Dr. Travers of Fort Madison,
president; Dr. Lapsley, vice-president, and Dr. Ran-
kin, secretary.
Linn County Medical Society
At the May 18 meeting of the Linn County Medical
Society, the following officers were elected: Presi-
dent, Dr. H. M. Ivins; vice-president. Dr. F. G. Mur-
ray; secretary. Dr. A. R. Zuercher; treasurer. Dr. W.
J. Neuzil; all of Cedar Rapids.
At this meeting a banquet was given in honor of
VoL. XII, No. 7 1
JocR.\'.\L OF low.A. State Medical Society
290
Dr. Edwin Burd of Lisbon, celebrating bis practice
of fifty years in the medical profession — sixty doc-
tors attended to do him honor. Following the ban-
quet and business session Dr. Howard L. Beye of the
State University presented a paper: “Three Cases,
Illustrating the Difficulty in Differential Diagnosis
between Sarcoma of the Bone and Infection of
Bone. Dr. B. P. Phemister of the State University,
gave a paper on “Bone Transplantation in the Treat-
ment of Ununited Fractures. A. R. Z.
Mahaska Medical Association
6oitre is a medical disease and must be treated as
such. Dr. Granville Ryan of Des ^Moines, specialist
in internal medicines, told members of the Mahaska
Medical Association at their monthh- luncheon at the
Chamber of Commerce.
Surgical treatment for goitre should always be fol-
lowed by medical attention. Dr. Ryan declared in the
talk on the subject of ‘Aledical Treatment of Goitre.’’
His talk was largely technical, based on studies here
and abroad and years of experience, and was a
scholarly consideration of the topic.
Doctors, their wives, and a few invited guests made
up the party which dined on roast chicken and all
the trimmings, served at the local club rooms.
Dr. F. J. Jarvis is president of the county organiza-
tion. Dr. F. A. Gillett is secretary.
The luncheon was the first of a series to be held
throughout the year and to be addressed by eminent
medical men of the country. Specialists in all lines
of the profession are to be brought here to address
the association, and possibly to conduct clinics.
State Society of Iowa Medical Women
The State .Society of Iowa Medical Women had a
most worth-while meeting May 9 in the Chamber of
Commerce library. .\bout thirty members were
I^resent and discussed some of the most important
aspects of preventive medicine, in addition to the
clinical papers. The morning session was most
profitably spent in hearing about the greater benefit
to be gained from the examination of the pre-school
age child than from the examination of high school
boys and girls. The papers of Dr. Josephine Rust
and Dr. Marian O’Harrow covered this field of work
in a very comprehensive manner.
At the afternoon session Dr. Rose Butterfield dis-
cussed some of the less used anesthetics, and Dr.
Mary Tinley of Council Bluffs gave a very concise
but vivid description of the result of toxemia in
pregnancy and some suggestions for its alleviation.
The paper by Dr. Pauline Hanson of Marshalltown
on Birth Control suggested the various phases of
this subject and brought forth much discussion.
The closing paper by Dr. Jennie Christ showed the
great contribution that the profession has made to-
ward the prevention of disease in the past few years.
Perhaps the pleasantest part of the day’s program
was the anniversary dinner at the Savery Hotel with
letters from five charter members of the society. Dr.
Edith h'osnes. Dr. Mary Breen, Dr. Evalene Peo,
Dr. Sara Kime, and Dr. Kate Mason Hogle.
Many reminiscences of the pioneer days were told
and the grave doubts of these organizers as to the
permanence of this venture were recalled.
Toasts to the past, present and future of our State
Society were given by Dr. Lena Beach of Rockwell
City and Dr. Jeannette Throckmorton of Des Moines.
The only charter member present at the meeting
was Dr. Josephine Wetmore Rust of Mason City,
who presided at the dinner in a most charming
manner. She read the names of the other six charter
memiters, only one of whom is thought to be still
living. They are Rebecca Hanna, Azuba King, Mary
-Ardery, Rebecca Wright, Jessie Smith and Mar-
garet Colby.
-A.t the business meeting it was voted to send a
delegate to the International Medical Association at
Geneva, Switzerland, if any one could attend the
meeting. Dr. Jennie Christ was appointed as the rep-
resentative of the society on the state committee on
women in industry.
The following officers were elected for the com-
ing year: President, Eppie McCrea, Eddyville; vice-
president, Jane Wright, Clear Lake; treasurer, Helen
Johnston, Des Moines; secretary, Julia F. Hill, Grin-
nell. Julia F. Hill, Sec’y.
Hahnemann Medical Society Meeting
The annual meeting of the Hahnemann Medical
-Association of Iowa was held in Des Moines with
headquarters at the Hotel Savery.
The morning session was held at the Iowa Con-
gregational Hospital where surgical and medical
clinics were held. Doctors E. A. Shaw, W. H. Mc-
Cartney, and G. A. Huntoon, of Des Moines, had
charge of the surgical clinic, while Doctors A. M.
Linn, H. L. Rowat, Erwin Schenk, and C. J. Loizeaux
had charge of the medical clinic. Miss Ada Hershey
and Doctors Alice H. Hatch and Jennie M. Coleman
were also on the program.
Dr. Fred Morgan, Clinton, gave the president’s
address.
Papers were read by Doctors Mel R. Waggoner of
Cedar Rapids, A. B. Clapp of Muscatine, E. E. Rich-
ardson of Webster City, W. W. Bailey of Davenport,
H. H. Humphrey of Indianola, and T. L. Hazard of
Iowa City.
Officers for the ensuing year chosen at the final
meeting were: Dr. M. A. Royal of Des Moines,
president; Dr. J. F. Battin, Marshalltown, first vice-
president; Dr. Alice H. Hatch of Des Moines, second
vice-president; Dr. J. Elso Neuland of Center Point,
secretary; Dr. A. B. Clapp of Muscatine, treasurer;
Dr. George Royal of Des Moines, editor of the
Homeopathic Journal of Iowa. The legislativ^e com-
mittee was re-elected. It includes Doctors George
Royal, -A. P. Hanchett, A. M. Linn, S. W. Staads and
C. H. Cogswell. The 1923 meeting will be held in
Des Moines.
300
Journal of Iowa State Medical Society
[July, 1922
Iowa Clinical Society
The Iowa Clinical Societj' met Tuesday, Jilay 9
at Hotel Fort Des Moines.
The clinical society which meets three times a
year, is composed of fifty members, all specialists in
internal medicine.
A clinic was held at Mercy Hospital, followed by
a luncheon at noon at Hotel Fort Des ^Moines, where
a business meeting was held in the afternoon.
The new officers are Dr. Frank A. Ely, Dca
Moines, president; Dr. C. A. Waterbury, Waterloo,
vice-president, and Dr. Russell Doolittle, Des
Moines, secretary-treasurer.
Sioux City Ear and Eye Specialists
Sioux City ear and eye specialists held their clos-
ing meeting for the past j^ear at the West Hotel and
elected officers for 1922-23. Dr. L. R. Tripp was
chosen president and Dr. F. W. Sallander secretary.
Dr. F. H. Roost, the retiring president, presided at
the meeting following dinner.
Dr. T. R. Gittins described the proceedings of
sessions of medical societies in the East that he re-
cently attended.
The Sioux City specialists will hold no more meet-
ings until fall.
Important Resolutions Adopted by the Radiological
Society of North America at Its Annual Meeting,
Chicago, 1920
Whereas: The question of the ownership of the
roentgenogram has never been definitely settled;
and.
Whereas: Other points regarding the ethics and
conduct of radiologists relative to the disposal of
their roentgenograms, records and reports of their
findings, have never been clearly outlined there-
fore, be it
Resolved, by the Radiological Society of North
.America, that it is the sense and judgment of this
society, that all roentgenograms, plates, films, nega-
tives, photographs, tracings or other records of ex-
aminations are hereby declared to be the exclusive
property of the radiologist who made them (or the
laboratory where they were made); and be it further
Resolved, That the ethics of this society shall be
in full harmony with the Principles of Medical Ethics
of the American Medical Association, with the fol-
lowing additions, to-wit:
The radiologist is hereby declared to be a con-
sultant in all cases where he is called upon to ex-
amine patients.
The radiologist shall not make known to patients,
their relatives, friends or guardians, any of his find-
ings or conclusions, nor shall he deliver to them any
of the plates, negatives, films or prints, unless ex-
pressly requested to do so by the pli3"sician or sur-
geon who referred the patient for examination, or is
in charge of the case. It shall be considered un-
ethical to advertise by circularizing in the medical or
lay press with price lists or fee tables, descriptions
or illustrations of office apparatus or facilities, or to
advertise by displaying signs stating the medical
specialty; or in the public press, telephone direc-
tories, or city, state or national directories, which are
published for general use.
It shall be considered unethical for any one to
claim superiority in diagnosis or treatment, due to
some secret process, method or apparatus held to
be known onlj' by the claimant.
Colorado Medicine, December, 1921.
HOSPITAL NOTES
Ten nurses received their diplomas of graduation
from the Lutheran Hospital, Hampton, at the com-
mencement exercises held at the nurses’ home on
South Reeve street Wednesday evening. May 3.
Four of Estherville’s doctors and surgeons have
joined hands in renting the Birney Hospital in this
city and will assume control of the same on June 1.
The four are Dr. Bachman, Dr. Morton, Dr. Wilson
and Dr. Bradley. Dr. Birney will also continue to
use the hospital for his cases, but will move his of-
fice from the hospital to the old office rooms over
the Estherville Drug Store.
The hospital, under the new management will be
renamed and made an institution in which all doctors
of this part of the state can work. Improvements
will be made where necessary and it will be one of
the most complete and best equipped hospitals in
northwest Iowa. The character of the men inter-
ested in the new venture is such that it will be a
popular institution. Each of the men has been prac-
ticing in Estherville for years, are well known to the
people of this community and the new combination
will command the respect of all. Patients will be
taken to the hospital by these four men from now on,
although active control of the institution will hot be
taken over until Tune 1. — Estherville Democrat.
The new east wing of Jennie Edmundson Me-
morial Hospital, costing in the neighborhood of
$200,000, was formally dedicated with impressive
ceremonies on the plaza in front of the main building
Sundaj^ afternoon, !May 14, with W. R. Orchard,
editor of The Nonpareil, as principal speaker.
The new hospital wing of four floors and an ob-
servatory attic with a doctors’ clinic room overlook-
ing the surgical laboratory on the floor below, is the
latest in modern hospital construction and will pro-
vide the most modern conveniences for hospital pa-
tients in Council Bluffs and vicinity.
With the enlarged heating plant and supplement-
ary ice plant as added features to the improvement of
the hospital the total cost will at least reach $250,000,
according to figures of Mrs. Emma L. Louie, busi-
ness manager of the institution.
The dedication ceremonies were opened with the
invocation b\' the Rev. Wilford Ernst Alann of St.
Paul’s Episcopal Church. In his introductory^ talk
VoL. XII, No. 7]
Journal of Iowa State Medical Society
301
Dr. Donald Macrae, member of the hospital staff and
leader of Mobile Hospital No. 1 in France, sought to
impress his audience with the value of a hospital to
a community.
Rapid progress is being made in the erection of
.Mien Memorial Hospital in Allen Heights on Lo-
gan avenue and the building will be under roof not
later than October 1, according to James Register,
senior member of Register & Buxton, contractors.
The Lutheran General Hospital of Sioux City, has
been reorganized and a new staff appointed consist-
ing of Drs. Townsend, Nervig and Henkin, in sur-
gery; Dr. Bellaire, radiology; Dr. Brandt and Dr.
Franchere, eye, ear, nose and throat; Dr. Vangsness
and Runyon, internal medicine; Dr. Harold Brown,
pediatrics; Dr. Latchem, urology; Dr. Victor Brown,
skin and venereal; Dr. O’Donaghue, orthopedics.
The hospital has just completed a new $120,000 addi-
tion and is being standardized.
PERSONAL MENTION
Dr. W. Fordyce of Fairfield, Iowa, made a week-
end visit with his daughter, Mrs. J. Roth. The
doctor is a remarkable man. He has practiced medi-
cine in Jefferson county for fifty years, and in recog-
nition of this fact the county medical society recently
gave a banquet in his honor. Nor has he the slight-
est intention of “retiring." He is just as active now
as he ever was and has a larger practice than ever.
He drives an automobile and goes over all kinds of
roads to see his patients and answers calls at any
hour, day or night. He is of rugged physique and
in the best of health and is a fine adv'ertisement for
himself. — Rock Rapids Review.
Dr. L. K. Fenlon of Clinton was a guest of Mr.
and Mrs. J. E. Wichman recently. He and Mrs.
Fenlon left for their home by way of Iowa City,
where they expected to make a short stop.
Dr. George S. Waterhouse, for many years a phy-
sician and surgeon at Charter Oak, but now located
at Mapleton, Iowa, suffered a paralytic stroke on
Friday evening, April 14, from which he is slowly re-
covering from reports received at this office.
Dr. R. U. Chapman, age eighty-five, of Des
Moines, who is one of the oldest practicing physi-
cians in Iowa, took an active interest in the sessions
of the Iowa Medical Society in session at the Hotel
Fort Des Moines. He began his practice of medicine
more than half a century ago.
Dr. Rodney P. Fagan, secretary of the state board
of health, left for Washington, May 16, 1922,
to attend a conference of state and provincial health
authorities with the United States surgeon general.
Subjects considered at this conference: inter-state
quarantine regulations, rural health work, child
hygiene and provisions of the Sheppard-Towner law,
advisability of state-wide application of Schick’s test
and toxin-antitoxin for the immunization of diph-
theria, and the eradication of rabies by vaccination
of dogs. The conference also look up the reports of
committees appointed at the previous conference
The .-\merican Water Works Association of the
United States held its annual meeting in Washing-
ton on the four days given over to the health con-
ference, and the delegates discussed matters of im-
portance to lowans, including the water supply for
railroad trains and precautions for preserving the
purity of the supply.
Dr. M. B. Dunning, who for a number of years
practiced medicine here is now located in the govern-
ment hospital at Denver. He holds the rank of
captain in the U. S. Army Medical Corps, and has
been stationed at various points in the United States.
He recently attended a government medical school
for special instruction at Washington and from there
was assigned to duty at the Fitzsimmons General
Hospital at Denver.
Dr. James T. Priestley has returned to his office
with the use of a cane. He is recovering from his
injuries in an automobile accident nicely and ex-
pects to be back to his office and practice in a few
days.
OBITUARY
Dr. Edmund R. Jenkins, pioneer Washington phy-
sician, who recently gave $15,000 to buy a site for the
Y. M. C. A. building here, died May 22 at eight
o’clock a. m. at his home. For the last two months
he had been seriously ill and death today came as a
relief from great suffering.
Always a man who had the best interests of the
community at heart. Dr. Jenkins in the closing days
of his life rendered the town of Washington a ser-
vice which will cause his name to be honored here
for many generations. His gift for a Y. il. C. A.
site enabled the community to realize on James H.
Young’s bequest for the “Y” building. It was the
crowning act of a life spent in the service of his
fellow men.
Dr. Jenkins was born at Corfu, New York, but
lived the greater part of his life in Iowa. He was
graduated from the Keokuk ^Medical College in 1874
and practiced his profession at West Chester for
eleven years, coming to Washington in 1885. He
has lived here ever since. On May 9, 1876, he was
married to Agnes C. Fletcher, who survives him.
They had one daughter, Miss Ada, who died in 1904.
In addition to his course at Keokuk, Dr. Jenkins
was graduated from Bellevue Medical College in
New York and also took a post-graduate course at
that school. He was one of the leading men in his
profession in this part of Iowa. His sympathetic
disposition and his skill as a physician made him one
of the best loved men in this whole community, and
he numbered his friends by the hundreds. The sym-
pathy of the community has gone out to him in his
long weeks of suffering.
302
loL’KNAL OK Iowa State I^Iedical Society
[July, 1922
The entire connmuiity was shocked and deeply
gricvetl to hear of the very >uddcn death of Dr. John
H. Stanton, at his late home in Chariton, at mid-
night, Thursday, May 2?, 1922, at the age of sixty
years, one month and one day, from cerebral hemor-
rhage.
Dr. Stanton was born at Spearsville, Brown
county, Indiana, April 24, 1862. When but an infant
he came to Lucas county, Iowa, with his parents, the
late Dr. and ^Irs. James E. Stanton. He .grew to
manhood in Chariton, received his medical education
as a physician and surgeon at Rush ^ledical College,
in Chicago, graduating in 1802, and practiced a short
DR. JOHN H. STAXTOX
time in Xebraska, but soon returned to Chariton,
where he has been engaged in a wide and successful
practice of medicine for the past thirty years.
On June 30, 1894, he was united in marriage to
Miss Gertrude Aughey the daughter of the late Rev.
and Mrs. John H. Aughey, who was for a number
of years the pastor of the local Presbyterian church.
'I'o this union were born four daughters, all of whom
with their mother survive. They are ilrs. Lester S.
Combs of Chariton, and Jessie, Elizabeth and ^lartha
at home. In addition to the immediate family, he is
survived bv two sisters — ^Irs. Alice Lockwood, iMrs.
Sam Boyles and one brother. Dr. T. P. Stanton, all
of Chariton.
Dr. Stanton was a man of strong convictions and
firmness of character, and as a consequence he had
a host of firm friends. His long residence in Chari-
ton gave him a wide range of acquaintance and bv
virtue of his profession he was brought into close
fellowship with multitudes of people as through the
vears of faithful, untiring ministry.
Dr. O. G. \\ inters of Des Moines, medical director
of the Yeomen, died Sundaj-, June 4, at the home of
his daughter, iMrs. John X. Schaeffer, 1240 Thirty-
second street.
Doctor Winters, who was an authority^ on insur-
ance matters, was a thirty-second degree iMason,
Knight Templar, Shriner, Yeoman and Woodman.
Surviving are his widow, his daughter and a son.
O. G. Winters, Jr., all of Des ^loines, and a sister,
Mrs. Kate Goodwin of Salt Lake City.
Dr. Winters was born December 2, 1858, at La
Crosse, Wisconsin. He was a graduate of Bellevue
Hospital College, Xew York. He practiced medi-
cine in La Crosse for a number of years.
He was appointed medical director of the Yeomen
in 1905 and has lived in Des Moines continuously
since that time.
In La Crosse he served as a member of the city
council, school board and city physician.
Dr. Charles D. Burke, forty-five, prominent Iowa
physician was found dead in his office at Atlantic.
June 19, from a stroke of paralysis.
Dr. Burke attained prominence in medical circle-
several years ago by his discovery of reflex symp-
toms of typhoid fever.
He was district examiner of the disabled veterans,
and a member of the state pension board.
He leaves a wife and son, and several sisters norv
in a Des iMoine.s convent.
BOOK REVIEWS
PAPERS FROM THE MAYO FOUXDATIOX
For Medical Education and Research and
the Graduate School of iMedicine of the Uni-
versity of ^Minnesota, Covering the Period of
1915-1920. Octavo Volume of 695 Pages with
203 Illustrations. W. B. Saunders Company,
Philadelphia and London, 1921. Cloth $10.00
Xet.
The character of the book compels us to refer
somewhat freely to the preface.
“The first obligation of a true university, that
makes it a university' and not an aggregation of
colleges, is to stimulate research, to attack unsolved
problems, to train its best students to ask and to an-
swer questions. The second obligation is to make
available the results of these investigations, is the
answers to these questions.”
Proceeding from this point of view, we come first
to the morphology' of the digestive and respiratory-
tracts. Hunger in the infant, gastric acidity from
the experimental point of view and .gastric acidity-
following gastroenterostomy, cancer of the stomach,
ulcers of the gastrointestinal tract, and a study of
the arteries of the stomach and duodenum.
Passing from the alimentary- tract comes the Uro-
genital Organs; the fundamental question involved
being the effect on the kidney- of various surgical
procedures on the blood supply, capsule, and on the
^'oL. XII, No. 7 1
Journal of Iowa State Medical Society
30.5
ureters. In addition, a miniber of detached observa-
tions are made on various subjects relating to the
urogenital organs.
The introductory and leading paper under Duct-
less Glands bears the title; The Morphogenisis of the
Follicles in the Human Thyroid Gland.
riic circulatory organs and blood receive similar
treatment.
Under the Division, Syphilis and Skin is an ex-
tended discussion of Squamous-cell, Epithelioma of
the Skin.
Under Division Nervous System are included eight
important papers, one of which is an interesting re-
view of the Pathogenesis of the Lesions of the Ner-
\ous System in Cases of Pernicious .Anemia; an-
other in Brain Changes Associated -with Pernicious
Anemia. In addition may be included a paper en-
titled The Influence of the \’agus Nerve on Respir-
ation.
.Among the papers under the head Trunk and Ex-
tremities is a notable paper on the Treatment of
Chronic Empyemia. *
In group nine may be found a series of studies on
Metabolism, and under group ten, general unclassi-
fied papers on various subjects.
The papers in this volume differ from those pub-
lished in the Mayo Clinic in that many of them are
based on original investigations prepared as a thesis
for the higher degrees in medicine and surgery. The
work is by mature investigators in special fields sup-
plied with almost unlimited material and facilities
under the direction of eminent teachers to meet the
re<iuirements set forth in the preface as the obliga-
tion of a university.
AN ESS.AA' ON THE PHYSIOLOGY OF AIIND
By Francis Dercum, AI.D., Ph.D., Pro-
fessor of Nervous and ^lental Diseases in
the Jefferson Medical College, Philadelphia;
12 AIo. of LSO Pages. \\’. B. Saunders Com-
pany, 1922. Cloth $1.7.t Net.
In this volume Professor Dercum has endeavored
to present to the reader who is interested in matters
relating to the nervous system and the mind, a
scientific discussion of what is known of the mind
I'o many perhaps. Dr. Dercum will appear material-
istic. but he docs not attempt to say what the mind
is or to discuss the dual conception of “mind and
matter,’’ rather to present a “saner conception of its
functions and limitations.”
In the beginning. Dr. Dercum outlines an archi
tectural plan of the ner\ous system; the properties
of living protoplasm, its capacity for transmission
of motion through its own substance, the differen-
tiation of pathways of transmission. A receiving
cell that receives the stimulus or “receptor,” a mus-
cle cell to which is conveyed the stimulus or “ef-
fector.’’ Later comes a transmitting structure be-
tween the receiving cell and the muscle cell. Thus
we have an elementary structure which corresponds
later to a differentiated nervous system which grows
more complex by additions. The many imiscle-cclls
becomes a restricted differentiated nerve cell group
joined by extension processes of two kinds, multiple
processes — dendrite.s — leadin.g to the cell body, the
oth.er extremity leading from the cell body known
as the axone. 'I'he mechanism becomes a terminal
end organ or receptor, an axone, a central organ or
effector, constituting a neurone, motor or sensory.
A multitude of these nervous and intercallated neu-
rone becomes a nervous system. With this archi-
tectural plan of a nervous system. Dr. Dercum pro-
ceeds in a synthetic manner to develop the activities
of the mechanism to meet the needs of its possessor
from the lower vertebrate animal to man. It is ;in
interesting study from a physiological and philo-
sophical point of view. If the author includes mind
;is one of the activities of a highly differentiated
nervous system he is only presenting the inevitable
facts of evolution.
PSYCHOAN.ALYSIS
The third edition of the publication entitled
Psychoanalysis, its theories and jiractical application,
by A. A. Brill, Ph.B., M.D., which has recently come
from the press, has been thoroughly revised in such
a manner as to keep pace with the everincreasing
and unending theories pertaining to the subject with
which it deals. .An added chapter pertaining to so-
called irregular sex habits really constitutes one of
the most important features of the work, since it
concisely states the modern and generally accepted
ideas on this subject. Another new feature of the
third edition deals with th.e psychanalytic explana-
tion of the mental mechanisms underlying the diag-
nostic “no-man’s land,” which Kraeplin has desig-
nated as paraphrenia.
Although many of us, including the writer, are not
psychanalytic extremists, the subject is nevertheless
of sufficient importance, to justify dignified consid-
eration, since it embodies many grains of scientific
truth mid the bushels of theoretical chaff. Hence
a contribution such as that afforded by this volume
on Psychoanalysis, should be accorded a place in ev-
ery well classified medical library.
F. A. Ely.
A TEXT-BOOK OF GENERAL
BACTERIOLOGY
By Edwin O. Iordan, Ph.D., Professor of
Bacteriology in the University of Chica.go
and in Rush Aledical College. Fully Illus-
trated. Seventh FYlition, Thoroughly Re-
vised. Philadelphia and London. W. B.
Saunders Company, 1922.
The seventh edition of this excellent text-book has
been extensively revised and brought up to date.
The book has many attractive features: The text-
book is tersely and clearly written, and is so ar-
304
Journal of Iowa State Medical Society
[July, 1922
ranged that the student will find it easy to dis-
tinguish between facts and theories. The author
has carefully evaluated the wealth of new bac-
teriologic literature. The bibliography contains the
most important new articles in bacteriology and
serves to enhance the value of the book materially,
in that it teaches the student from what sources the
author has obtained his material and at the same
time furnishes valuable aid to the original worker.
The present edition further contains an adequate de-
scription of the most modern standard bacteriologic
technic, which increases the value of the book very
much to all who are doing bacteriologic work. The
modern conception of immunology and the basic
principles of serology are admirably and clearly set
forth in the present edition. The chapters dealing
with the unknown causes of infection diseases, on
disease producing protozoa, and those dealing with
bacteria in art and industries have been brought up
to date so that the book in its present form, serves
in a classical way a two-fold purpose, viz. — that of a
scientific text-book for medical students and a ref-
erence work in bacteriology.
Daniel T. Glomset.
DISEASES OF THE EYE
A Hand Book of Ophthalmic Practice for
Students and Practitioners. By George E.
deSchweinitz, M.D., LL.D., Professor of
Ophthalmology in the University of Penn-
sylvania; Ninth Edition, Reset; Octavo of
832 Pages with 415 Text-Illustrations and 7
Colored I’lates. Philadelphia and London.
\V. B. Saunders Company, 1921. Cloth
$10.00 Net.
The eighth edition of this book appeared in 1917.
Needless to say that in the four years which have
elapsed since the appearance of the eighth edition
there have been many advances in our knowledge of
Ophthalmology and that these advances have been
exceptionally rapid is shown in this new edition.
The author states that he has utilized within the
limitations of a book of this character the extensive
literature and the unusual opportunities which the
W orld’s War has given rise to.
Numerous subjects appear for the first time. Some
of them are; Tenning's Self-Recording Test for Col-
ored Blindness; Measurement of Accommodation by
Skiascopy; Electric Desiccation in the Treatment of
Lid Carcinomas and Epibulbar growths; L’nusual
Forms of Conjunctivitis; Striate Clearing of Corneal
Opacities; Trypanosoma Keratitis; Superficial
Linear Keratitis; Keratitis Pustuliformis Profunda;
Primary Progressive Calcareous Degeneration of
the Cornea; .\nterior Lenticonus; Localization and
Organization of the Cortical Centers of Vision ac-
cording to Holmes and Lester; Contusion and Con-
cussion of the Eyeball in Warfare.
This edition although containing seventy-eight
more pages of text is slightly smaller in size than
the previous one. There are forty-si.x pages on
general optical principles, forty-five pages on exam-
ination of patient, 73 pages on ophthalmoscopy,
skiascopy and refraction, 487 pages covering the va-
rious diseases of the eye. The chapter on opera-
tions contains 108 pages, it has been enlarged six-
teen pages and contains fifteen new surgical pro-
cedures not mentioned in the previous edition. The
chapters on refraction and fitting of glasses are ex-
cellent and of value to everyone doing this kind of
work. Numerous foot note references to important
publications have been inserted and a number of
new illustrations have been added.
This edition bears throughout evidences of care-
ful and thorough revision. The subjects are handled
in a systematic way, the definitions and explanations
are clear and concise. It is up to date and con-
tains much new accurate information in readily ac-
cessible form and should be in the libraries of every
one interested in ophthalmology.
E. P. Weih.
.SUBMUCOUS RESECTION OF THE NASAL
SEPTUM
By W. Meddaugh Dunning, !M.D., Consult-
ing Otologist. Fordham Hospital, N. V. C.;
Consulting Otologist, Manhattan State Hos-
pital, N. Y. ; Consulting Laryngologist, Os-
sining City Hospital, Ossining, N. Y. ; Con-
sulting Laryngologist, The Alexander Linn
Hospital, Sussex, N. J.; .Assistant Manhattan
Eye and Ear Hospital, New York; Surgeon,
Bronx Eye and Ear Infirmary, New York.
Published by Surgery Publishing Company,
New York City. Price $1.50.
This book contains one hundred pages, is illus-
trated by twenty-five pages of drawings, printed
upon heavy coated paper and substantially bound in
cloth. The work is divided into eight chapters and
covers thoroughly! The Nose, Breathing and Smel-
ling, Common Septal Deviations, Surgical Procedure
in Submucous Resection of the Nasal Septum,
Special Surgical Procedure, Typical Case Histories
and Their Significance, The Saddle-back Nose, etc.
The first five chapters of the book appear as a
scries of articles in the January, February and
March, 1921 numbers of the .\merican Journal of
Surger_\-. These have been e.xpanded, and revised,
and with the addition of three chapters have been
published in book form.
The subject matter is largely a resume of the
professions knowledge of the subject wJth observa-
tions drawn from the writer’s experience. The us-
ual method of anesthetizing a septum with cocain
and adrenalin is explained in great detail, but there is
no mention of the use of sub-periosteal injection of
novocain for anesthesia and elevation of the perios-
teum from spurs. Several pages are devoted to the
use of the Dunning Curette Elevator.
The book is recommended to all surgeons who are
VoL. XII, No. 7J
Journal of Iowa State Medical Society
305
interested in this operation with the liope that in
its pages they may learn something which will be of
benefit to the procession of septal deviations still to
come. E. P. Weih.
CLINICAL DIAGNOSIS
A Text-’Iook of Clinical Microscopy and
Clinical Chemistry for Medical Students,
Laboratory Workers and Practitioners of
Medicine. By Charles Philips Emerson, A.
B., M.D. Late Resident Physician Johns
Hopkins Hospital and Associate in Medi-
cine. Professor of Medicine, Indiana Uni-
versity School of Medicine, 156 Illustrations;
Fifth Edition. J. B. Lippincott Co.
The last edition of Professor Emerson’s book ap-
peared ten years ago and so many things have hap-
pened in clinical diagnosis that practically a new
work has been necessary, avoiding the possible over-
sight of errors which are sometimes repeated in new
editions. This is not a laboratory manual, as its
title might imply, but a clinical discussion in which
the laboratory is of fundamental importance.
The first chapter relates to the Sputum. The
second chapter to the Urine. Then follow Gastric
Contents, and Intestinal Contents. The Blood and
Spinal Fluid receive extended consideration. The
value of this work is not limited to physicians who
do their own laboratory work but extends to men
who employ a laboratory assistant. Laboratory ob-
servations to be of value should be directed by the
physician who is conversant with the value of lab-
oratory findings and this is evaluated by the some-
what extended discussion of clinical points of con-
tact. The general practitioner will find this book of
very considerable value in his daily work.
TRANSACTIONS OF THE COLLEGE OF PHY-
SICIANS OF PHILADELPHIA
Third Series, Volume The Forty-Second;
Printed for the College, 1920.
Few volumes reach our table more welcomed than
the Transactions of the Philadelphia College of Phy-
sicians. The contributions contained represent the
best of a cultured medical fraternity; they are care-
fully prepared and impress the highest ideals of a
profession that sometimes seems almost at war.
The first that impresses us is a fine portrait of
one of Philadelphia’s most distinguished surgeons
and citizens. Dr. Richard Hart. There are a number
of technical papers, but what appeals to us most is a
series of memoirs and reminiscences of physicians
who have made Philadelphia medicine famous. Sir
William Osier, by Dr. Thomas McCrae; by Dr. Ho-
bart Amory Hare; by Dr. Charles W. Burr; by Dr.
George William Norris.
Dr. H. C. Wood, by Dr. G. E. de Schweinitz; by
Dr. F. X. Dercum; by Dr. Hobart .^mory Hare; by
Dr. William Henry Bennett; by Dr. D. T. ^lilton
Miller.
The Reminiscences of Dr. H. C. Wood written by
himself toward the close of his life and edited by
Dr.de Schweinitz are e.xceedingly interesting and will
be read I am sure by the generation of physicians
who are passing away, with the deepest interest.
Although Dr. H. C. Wood died only two years ago
(January 3, 1920), yet his name is only a tradition,
so little is thought of the men who contributed so
much to the advancement of medicine, by the gen-
eration of physicians who today occupy the field.
The sections on Ophthalmology and Industrial
Medicine are of exceeding interest.
ANNUAL REPORT OF THE SURGEON OF
THE PUBLIC HEALTH SERVICE OF THE
UNITED STATES
For the Fiscal Year 1921. — Government
Printing Office.
This volume of 430 pages contains a great mass of
valuable information concerning the activities of
this most important department of government. In
view of its accomplishments it seems almost impos-
sible that congress could afford in any way to refuse
to grant liberal appropriations to carry on the work
and to maintain the highest degree of efficiency.
SOUTH AMERICA FROM A SURGEON’S
POINT OF VIEW
By Franklin H. Martin, C.M.G., M.D.,
F.A.C.S., Director-General American College
of Surgeons, Managing Editor Surgery,
Gynecology and Obstetrics. Introduction
by William J. Mayo, M.D., F.A.C.S.
This exceedingly interesting account of South
.America written by one of America’s most distin-
guished surgeons in colaboration with Dr. W. J.
Mayo, presents a story unequaled in interest by any-
thing we have read concerning this great country.
Doctor and Mrs. Martin and Doctor and Mrs. Mayo
visited these countries under unusually favorable
auspices, not only did they visit as North .American
surgeons but as representatives of the United States,
and received honors due them not only as distin-
guished individual citizens, but as citizens of a great
country.
.Aside from the high literary merits of the story
we are furnished with information unknown to us
before concerning the people from a certain point
of view, and particularly concerning the medical pro-
fession in their homes: their work, and facilities
and methods of work.
Starting from “our dream days of youth and Rob-
inson Crusoe to their return from some far off lands
of the South Seas’’ we may follow this favored group
from one point of interest to another preaching the
doctrine of professional unity with the result of
fifty conversions to the shrine of the .American
College of Surgeons.
The book is beautifully illustrated and with the
personal reminiscences, and with the personal ob-
306
Journal of Iowa State Medical Society
[July. 1922
servations of tlic men of oiir own profession and the
people among whom they work, their environment,
the scenery, customs and manners brings a fund of
information wdiich must greatly influence us in our
relations with a people, we had known little about in
a direct way.
There is a historical, geographical, political, social
and industrial summary, and also a vocabulary, that
will in many ways be helpful in getting crooked
things straight.
THE MEDICAL DEl’ARTMEXT OF THE
EXITED STATES .\RMY IX THE WORLD
WAR
Volume 15, Statistics, Part One Army An-
thropology. Based on Observations Made
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MEDICAL AXD SURGICAL REPORTS OF THE
EITSCOl’AL HOSPITAL OF PHILA-
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\’olume Five, Wm. J. Dornan, Publisher.
This volume of 500 pages contains contributions
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surgeons and specialists.
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®f)e Jfournal of tfje
^Hotoa ^tate j^lefiical
VoL. XII Des Moines, Iowa, August 15, 1922 No. 8
DIGITALIS IN CARDI.\C DISEASE*
Henry A. Christian, M.D., Boston
In seeking a topic on which to address you it
seemed to me desirable to select one that con-
cerned the majority of you and which might bring
to you some suggestions that would be helpful in
your usual routine of work. Mhth this in mind
I suggested two topics to your committee, and
they selected the one on digitalis therapy. I be-
lieve they made a good choice, for in my expe-
rience there are many misconceptions in regard to
digitalis among practitioners judged from their
use of the drug on patients that subsequently have
come under my care.
Certain more or less categorical statements may
be made with advantage about digitalis, and some
of these I will use to preface ni}- remarks.
The dangers or toxic effects of digitalis are
more serious as met with in medical books than
in medical practice.
.Some one of these toxic effects or so-called digi-
talis dangers really should be sought rather than
avoided in digitalis therapy.
The real dangers in digitalis therapy are three :
(a) using a poor digitalis preparation; (b) con-
sciously or unconsciously prescribing too little of
a ])otent digitalis preparation; (c) not knowing
when digitalis should be started and stop])ed.
Digitalis usually is gi\en in too .small, i. e.,
insufficient dosage. I have yet to see the patient
in whom too much digitalis had been given prior
to my seeing the j>atient. I have given too much,
i. e., a harmful dose of digitalis, myself to my
knowledge just once, knowingly then taking a
chance in a desperate case. The large majority
of cardiac patients seen by me have had too little
digitalis ; a .small percentage have had enough dig-
italis ; none have had too much ; some have had
too little or enough from the point of view of
dosage when actually they should have had none.
Genuine digitalis poisoning, of course, is possi-
ble, but it is one of the rarities of medicine.
■•Address before the Iowa State Medical Society at the Seventy-
first Annual Session, Des Moines, May 10. 11. 12, 1022.
Digitalises good for the symptoms and physi-
cal signs the patient has provided those symptoms
and signs are the result of cardiac insufficiency,
i. e., decompensation.
1'he indications for starting digitalis therapy
are the presence of symptoms and physical signs
which are the result of cardiac insufficiency, i. e.,
decomj)ensation.
The symptoms and physical signs of cardiac in-
Chart I. Male, age 28, chronic cardiac valvular
disease, mitral stenosis; rhythm regular. The first
column of figures on the left hand side of the chart
indicates the amount of urine output and the fluid
intake for each 24 hours expressed in c.c. The sec-
ond column of figures on the left of the chart indi-
cates the apex and radial pulse rates per minute
D = 3 doses of 0.2 gm. each of powdered digitalis
leaves every 6 hours, a total of 0.6 gm. on this day.
Di = 7 doses of 0.3 gm. each of powdered digitalis
leaves every 6 hours, a total of 2. 1 gm. on this day
Total D -|- Di = 2.7 gm. of powdered digitalis leaves.
P = pulse rate counted at the wrist. F = fluid intake
measured in c.c. U = measured in c.c. The effect
of digitalis in this case was a slowed pulse (110 —
.35) and on two days a marked diuresis, with urine
increase from 400 to 2700 and 2500 c.c.
308
Journal of Iowa State Medical Society
[August, 1922
sufficiency are breathlessness, cough, cyanosis,
edema, pain, weakness, nausea, vomiting, enlarge-
ment of the liver, decreased urine output, rapid
pulse.
The indications for stopping digitalis are im-
provement in these symptoms and signs or the
Chart II. Male, age 60, chronic myocarditis,
rhythm regular. The first column of figures on the
left hand side of the chart indicates the amount of
urine output and the fluid intake for each 24 hours
expressed in c.c. The second column of figures on
the left of the chart indicates the apex and radial
pulse rates per minute. The column of figures on
the right indicates the weight of the patient in kilo-
grams. 1) = 8 doses of 0.2 gm. each of powdered
digitalis leaves every 6 hours, a total of 1.6 gm. P =
pulse rate counted at the wrist. F = fluid intake
measured in c.c. U = urine measured in c.c. VV =
weight of the patient in kilograms. The effect of
digitalis in this case was a moderately slowed pulse
rate (8.^ to 60), a diuresis with urine increase from
62.S to 975 and 2300 c.c., and a decrease in body
weight of 7.8 kilos, or 17.2 pounds.
occurrence of some of the toxic effects of dig-
italis.
The toxic effects of digitalis are nausea, vomit-
ing, certain arrhythmias, as bigeminal pulse and
heart block, rarely diarrhea.
There are a number of misconceptions about
digitalis therapy now in vogue, some very gen-
erally. Some of these are: (a) that a regular
pulse indicates that a poor digitalis effect will be
obtained; (b) that striking digitalis effects are
confined to patients with auricular fibrillation;
(c) that a slow ])ulse indicates that a poor digi-
talis effect will be obtained; (d) that a fast pulse
is an indication for the use of digitalis; (e) that
a murmur is an indication for the use of digitalis ;
ff) that cardiac enlargement is an indication for
digitalis; (g) that aortic insufficiency is a con-
traindication for digitalis; (h) that myocardial
degeneration is a contraindication for digitalis ;
(i) that high blood-pressure is a contraindication
for digitalis; (j) that arteriosclerosis is a con-
traindication for digitalis; (k) that angina pec-
toris is a contraindication for digitalis; (1) that
nausea and vomiting are due to some undesirable
constituents in the digitalis pre]>aration that may
be removed by pharmaceutical art.
Other misconceptions might be enumerated but
sufficient have been given to occupy us at present.
Now let us elaborate somewhat on those of the
above statements that do not seem clear or for
Chart III. Female, age 45, chronic myocarditis,
auricular fibrillation. The first column of figures
on the left hand side of the chart indicates the
amount of urine output and the fluid intake for each
24 hours expressed in c.c. The second column of
figures on the left of the chart indicates the apex
and radial pulse rates per minute. The column of
figures on the right indicates the weight of the pa-
tient in kilograms. D = 0.5 gm. of powdered digi-
talis leaves given at 3:35 p. m. I)i = 9 doses of 0.2
gm. each of powdered digitalis leaves given 4 times a
day, a total of 1.8 gm. Total D -F I)i =2.3 gm. of pow-
dered digitalis leaves. = heart rate counted with
a stethoscope over the apex region. P = pulse rate
counted at the wrist. F = fluid intake measured in
c.c. U = urine measured in c.c. W = weight of the
patient in kilograms. The effect of digitalis in this
case was a diuresis with urine output of 2250 c.c. and
a decrease in body weight of 7 kilos, or 15.4 pounds.
VoL. XII,No. 8|
Journal of Iowa State Medical Society
309
which further evidence ;i])}tears to be desirable.
As to the toxic effects and dangers of digitalis
little need be added to what I have already said.
The striking fact is that serious toxic effects and
real harm from digitalis theraj)y are almost never
seen. Very often symptoms regarded as the re-
.sult of digitalis are really due to failure to give
enough digitalis to control cardiac symptoms. So
often digitalis is stopi)ed or some other cardiac
drug is used because of nausea when it is more
Chart IV. Female, age 28, chronic cardiac val-
vular disease, mitral stenosis and regurgitation,
aortic regurgitation; auricular fibrillation. The first
column of figures on the left hand side of the chart
indicates the amount of urine output and the fluid
intake for each 24 hours expressed in c.c. The sec-
ond column of figures on the left of the chart indi-
cates the apex and radial pulse rates per minute. D
= 1 c.c. tincture of digitalis given intravenously at
10:12 a. m. Di = 2 doses of 0.5 gm. of powdered
digitalis leaves given at 1:52 and 8 p. m., a total of
1 gm. D2 = 2 doses of 0.1 gm. of powdered digitalis
leaves given at 6 and 10 p. m., a total of 0.2 gm.
Total D -F Di + D2 = 1 c.c. of tincture intravenously
and 1.2 gm. of powdered leaves by mouth. A =
heart rate counted with a stethoscope over the apex
region. P = pulse rate counted at the wrist. F =
fluid intake measured in c.c. U = urine measured
in c.c. The effect of digitalis in this case was a
slowed apex rate (190 to 70), with disappearance of
pulse deficit.
Chart V. Male, age 57, chronic myocarditis, au-
ricular fibrillation. The first column of figures on
the left hand side of the chart indicates the amount
of urine output and fluid intake for each 24 hours ex-
pressed in c.c. The second column of figures on the
left of the chart indicates the apex and pulse rates
per minute. The arrows of A~ indicate days on
which the patient received three doses of 0.1 gm.
each of powdered digitalis leaves. A = heart rate
counted with a stethoscope over the apex region. P
= pulse rate counted at the wrist. F = fluid intake
measured in c.c. U = urine measured in c.c. The
effect of digitalis in this case was a marked slowing
of the heart rate from 140 to 74 and a diuresis with
urine increase from 550 to 2525 and 5550 c.c. per 24
hours.
digitalis, not less, that is needed to abate the
nausea.
It needs to be recognized that very often the
digitalis which the patient purchases has but
slight jx)tency. A serious error is to regard a
drop as a minim and to prescribe fifteen drops of
tincture of digitalis thinking to give fifteen
310 Journal of Iowa Sj
Chart \’I. Male, age 35, chronic myocarditis, reg-
ular rhythm. The first column of figures on the
left hand side of the chart indicates the amount of
urine output and fluid intake for each 24 hours ex-
pressed in c.c. The second column of figures on the
left of the chart indicates the apex and pulse rates
per minute. Arrow over Ai indicates intramuscular
dose of 1 c.c. of digipuratum. Arrows over A^ indicate
days on which the patient received three doses of 0.1
gm. each of powdered digitalis leaves. P = pulse
rate counted at the wrist. F = fluid intake measured
in c.c. U = urine measured in c.c. The effect of
digitalis in this case was a marked slowing of the
pulse from 135 to 72.
minims ; the patient taking fifteen drops often
gets but five minims, rarely more than seven,
both very small doses. This error accounts for
much unconscious prescribing of too small a dose.
The rest comes from the digitalis being of low
potence. I would urge on you the abandoning
entirely of directing your patients to take anj^
number of drops of digitalis tincture; most desir-
able doses contain too many drops to ask your
ATE Mkuical Society [August, 1922-
patient to use such a crude method of measure-
ment. f
All too often digitalis is given on the part of
the physician when the indications for its use are
not evident. There should be definite evidences
of cardiac insufficiency before digitalis is given.
Increased heart rate alone is never the result of
cardiac insufficiency and never the indication for
digitalis therapy. This may seem a strong state-
ment, but following it, will, I am sure, improve
your digitalis therapy and save you from giving
it when it will do no good and may do harm.
Paroxysmal tachycardia does not resppnd to digi-
talis and digitalis does not effect simple tachy-
cardia. In infectious diseases a rapid'T-egular
pulse, in my opinion, is not an indication for dig-
italis, and its use will do your patient no good.
I see no advantage in the routine use of digitalis
in pneumonia, a quite usual procedure. In the
pneumonia doing badly with a rapid, weak pulse,
I have never seen digitalis help and I have stopped
using it in such cases. If auricular fibrillation
develops or cardiac decompensation is present
digitalis is very useful. It then behooves prac-
titioners to recognize clearly what are the symp-
toms and signs of cardiac decompensation, and
the.se I have already ©numerated. Here I should
add that no nijurmur of whatsoever sort, nor en-
largement of the heart, in itself is an’ indication
for digitalis therapy. If symptoms and signs of
cardiac insufficiency are present give digitalis
until they improve or until some of the toxic ef-
fects of digitalis appear. The remarkable thing
is that but extremely few cardiac cases fail to
show some improvement in some of the evidences
of cardiac decompensation when adequate dosage
of digitalis is used. In ninety-seven consecutive
adult cases of my own eighty-onp showed definite
symptoms or signs of cardiac decompensation.
Ninety per cent of these showed definite improve-
ment in cardiac condition following digitalis ther-
apy. The nine failures resulted from close ap-
proach of death in six, aortic aneurysm in one,
chronic nephritis that prevented diuresis in one,
and there was no apparent reason in one.
That a regular pulse indicates that a poor digi-
talis effect will be obtained is not borne out by '
the chart of the following case (Chart I). This
patient was a male of twenty-eight years of age
with mitral stenosis and regular rhythm. Digi-
talis produced a slowing of the pulse from 110
to 55 and on two days there was a marked diure-
sis with urine increasing from -KX) to 2700 and
2500 cc. per twenty-four hours. Such good digi-
talis effects were obtained in 72.5 per cent of a
Yol. XII, No. 8]
Journal of Iowa State Medical Society
311
serie.^ of patients with a rej^ular rhythm studie l
by me.
That striking digitalis effects are confined to
jiatients with auricular fibrillation is not borne
out by my experience, for in ninety-seven consec-
utive adult cases, of which forty had regular rates
and fifty-seven fibrillated, definite digitalis ef-
fects were obtained irrespective of regular rhythm
or fibrillation, the percentage being 72.5 per
cent for regular rhythm and 75.4 per cent for
auricular fibrillation.
.A.S to a slow pulse indicating a poor digitalis
effect the charts of the following cases show that
this does not hold true. The first patient was a
male, age sixty, with chronic myocarditis and reg-
ular rhythm. In this patient the effect of digi-
talis (Chart II j was a verj' moderate slowing of
the pulse rate from 85 to 60, an increase in urine
output from 625 to 975 and 2300 cc. per twenty-
four hours, and a decrease in body weight of 7.8
kilos or 17.2 pounds. The second patient was a
female age forty-five with chronic myocarditis
and auricular fibrillation. The effect of the
digitalis in this case (Chart III) was a diuresis,
increasing the urine to 2250 cc. in twenty-four
hours, and a decrease in body weight of seven
kilos or 15.4 pounds.
As to aortic insufficiency being a contraindica-
tion for digitalis, it is generally held now that
digitalis does not at all increase the probability of
the heart stopping in diastole on the theory that
digitalis prolongs diastole in its slowing effect on
the heart and so increases the regurgitation of
blood back from the aorta leading to over disten-
tion of the left ventricle. Perhaps excellent
digitalis effects are not obtained as regularly with
aortic insufficiency as with other valve lesions,
but often they are extremely satisfactory as
shown by the chart of the following case. This
patient was a female, age twenty-eight, with
aortic regurgitation and mitral stenosis and re-
gurgitation. She had auricular fibrillation. The
effect of digitalis (Chart IV) was to slow the
apex rate from 190 to 70 and cause a disappear-
ance of the pulse deficit.
The statement that myocardial degeneration is
a contraindication for digitalis is not in harmonv
with the striking effects obtained in auricular fi-
brillation which is an indication of myocardial
disease. Nor is it in accord with the splendid re-
sults of digitalis obtained in chronic myocarditis
as already illustrated by Chart III and I\'. Chart
^ V of a middle aged man with chronic myocarditis
and auricular fibrillation shows particularly well
a digitalis effect with slowing of the apex rate
from 140 to 74 and a diuresis from 700 to 2550
Chart VII. Male, age 45, chronic myocarditis, hy-
pertension, rhythm regular. The first column of fig-
ures on the left hand side of the chart indicates the
amount of urine output and the fluid intake for each
24 hours expressed in c.c. The second column of
figures on the left of the chart indicates the apex and
radial pulse rates per minute. The column of fig-
ures on the right indicates the weight of the patient
in kilograms. D = a single dose of 2.3 gm. of pow-
312
Journal of Iowa State Medical Society
[August, 1922
dered digitalis leaves given at 10:30 a. m. P =
pulse rate counted at the wrist. F = fluid intake
measured in c.c. U = urine measured in c.c. W =
weight of the patient in kilograms. The effect of
digitalis in this case was to produce a very marked
diuresis with increase of urine from ItKKl to 6425,
5050, 2625 and 2600 c.c., and a decrease in body
weight of 21.4 kilos, or 47 pounds.
Chart Vlll. Female, age 43, chronic myocarditis,
hypertension, rhythm regular. The first column of
figures on the left hand side of the chart indicates
the amount of urine output and the fluid intake for
each 24 hours expressed in c.c. The second column
of figures on the left of the chart indicates the apex
and radial pulse rates per minute. The column of
figures on the right indicates the weight of the pa-
tient in kilograms. D = a single dose of 1.2 gm. of
powdered digitalis leaves given at 9:30 p. m. =
5 doses of 0.2 gm. each of powdered digitalis leaves
every 6 hours, started at 3:30 a. m., a total of 1 gm.
Total D 1)1 = 2.2 gm. of powdered digitalis leaves.
P = pulse rate counted at the wrist. F = fluid in-
take measured in c.c. U = urine measured in c.c.
\V = weight of the patient in kilograms. The effect
of digitalis in this case was a slight prolonged
diuresis and a decrease in body weight of 15 kilos, or
33 pounds.
and 5100 cc. jter twenty-four hours. Even with
pulsus alternans, one of the best indications we
have of severe mvocardial disease, splendid re-
sults may follow digitalis as shown in the follow-
ing case. Here in a man of middle age with
chronic myocarditis, the electrocardiograms
showed a regular cardiac rhythm, but trac-
ings from the brachial artery indicated a marked
degree of pulsus alternans. Digitalis under these
conditions, however, produced (Chart \'I) a
marked slowing of the pulse from an average of
125 to 72. In just the same way, hypertension,
arterio.sclerosis and angina pectoris are not con-
traindications for digitalis. With all of these ex-
cellent digitalis effects are obtained. The follow-
ing ca.ses may serve to illustrate this. In the first
patient of this group there was a chronic myo-
carditis with hypertension and a regular cardiac
rhythm in a male, age forty-five. Digitalis here
produced (Chart VII) a very marked diuresis, in-
creasing the urine from KXX) cc. to 6425, 5050,
2625 and 2600 cc. per twenty-four hours and de-
creased the body weight by 21.4 kilos or forty-
seven }X)unds. In a second case there was hyper-
tension and chronic myocarditis in a woman of
forty-three who had a regular cardiac rhythm.
Here the effect of digitalis was (Chart VHI) a
slight prolonged diuresis and a decrease in body
weight of fifteen kilos or thirty-three pounds. In
a man of fifty-nine with chronic myocarditis,
auricular fibrillation, marked arteriosclerosis and
a former right sided hemiplegia, digitalis pro-
duced (Chart IX) a delayed decrease in the apex
rate from 1 10 to 78, a delayed but prolonged mod-
erate diuresis and a decrease in body weight of
nineteen kilos or 41.8 pounds.
Finally a word as to the misconception that
nausea and vomiting are due to some undesirable
constituent of digitalis that may be removed by
pharmaceutical art. Hatcher’s experimental work
has shown clearly that nau.sea and vomiting are
central toxic effects of digitalis on the vomiting
center and not a local action on the gastric mu-
cosa. My own experience has been that digitalis
in its simplest form, namely, as powdered leaves,
does not produce nausea and vomiting until other
definite digitalis effects are manifest, and that it
mav be used advantageously in almost every car-
diac patient even when nauseated and vomiting.
I have often tried ]>reparations supposed to have
been freed of their objectionable gastric action. *
The result uniformly is that either they produce
nausea and vomiting just as promptly as the sim-
VoL. XII, No. 8]
Journal of Iowa State Medical Society
313
pie powdered digitalis or if they do not, it is be-
cause they are not potent preparations, i. e., they
do not give satisfactory digitalis effects. My own
experience is that digitalis lutea, claimed to have
less toxic effects than digitalis purpurea, pro-
duces the same nausea when the two are used in
corresponding dosage. I doubt whether it is very
likely that a digitalis preparation will ever be pro-
duced which will give satisfactorily digitalis ef-
fects and not cause nausea. I even question
whether such a preparation is really desirable.
Nausea is, after all, a very useful, easily recog-
nizable effect of sufficient digitalis, and so serves
a very useful purpose in digitalis therapy. If
one is carefully watching his patients in many
instances full therapeutic effects of digitalis may
be obtained without causing nausea and if nausea
does result it need not be severe. Marked nausea
and vomiting occur in reverse ratio to the care
that is being given to the observation of one’s pa-
tients. Anyhow I firmly believe that so far no
pharmaceutical art has succeeded in removing the
nausea producing portion of digitalis and left be-
hind its needed therapeutic portions. After a
fair trial of the various available digitalis prepar-
ations, I feel convinced that none are superior to
digitalis in its simplest form, the leaves powdered
and mixed with a sticky vehicle so as to make a
pill.
Digitalis may be given in a single jnassive dose,
or in a modified massive dose method, or in reg-
ularly repeated small doses. Any of these meth-
ods is effective. The chief difference lies in the
length of time needed to produce a result. For
the average cardiac case there is no real prefer-
ence. In a few very severe cases the modified
massive dose method is better. Occasionally the
single massive dose may be life saving. When all
is done and said, digitalis therapy is very simple.
Just give enough of a potent leaf, prepared in
anynvay, by any accepted method of dosage, and
the result is most satisfactory in almost every
case. So far I have never seen a patient to whom
digitalis could not be given when it was indicated
by symptoms and physical signs without doing
the patient harm and almost always with excel-
lent results. I know of no cardiac case in which
it is necessary to substitute any other drug for
digitalis, and I consider powdered leaves of digi-
talis in pill form a thoroughly satisfactory prepar-
ation. In seven years use at the Peter Bent
Brigham Hospital I have seen digitalis leaves of
different strengths, but so far we have never
purchased a leaf that was unsatisfactory in its
results, and except for periods of testing some
particular preparation, we have consistently ad-
hered to using powdered leaves in pill form be-
Chart IX. Male, age 59, chronic myocarditis, au-
ricular fibrillation, arteriosclerosis, old right hemi-
plegia. The first column of figures on the left hand
side of the chart indicates the amount of urine out-
put and the fluid intake for each 24 hours expressed
in c.c. The second column of figures on the left of
the chart indicates the apex and radial pulse rates per
minute. The column of figures on the right indi-
cates the weight of the patient in kilograms. D = a
single dose of 1.8 gm. of powdered digitalis leaves.
Dt = 0.2 gm. of powdered digitalis leaves. D2 = 15
doses of 0.1 gm. each of powdered digitalis leaves
every 6 hours, a total of 1.5 gm. Total D Di -f- D2
=: 3.5 gm. of powdered digitalis leaves. A = heart
rate counted with a stethoscope over the apex re-
gion. P = pulse rate counted at the wrist. F =
fluid intake measured in c.c. U = urine measured
in c.c. W = weight of the patient in kilograms. The
effect of digitalis in this case was a delayed decrease
in apex rate (110 to 78), with a moderate decrease in
pulse deficit, a delayed but prolonged moderate
diuresis, and a decrease in body weight of 19 kilos, or
41.8 pounds.
cause the results were thoroughly satisfactory.
We have found that using a new sample of leaves
on a group of patients was an eminently satis-
factory way of finding out the potency of the
leaf and the most effective dosage. Standardiz-
ing on animals is helpful but by no means essen-
tial. For much of the time we have not standard-
ized our leaves on animals and still our results
are satisfactory. I am saying this not to decry
animal standardization but merely to show that
it is not essential to good digitalis therapy in the
hands of one with as much as several cardiac
cases constantly on hand for treatment.
314
THE EFFECT OF OCCLUSION OF THE
CORONARY ARTERIES ON THE
HEART’S ACTION AND ITS RE-
LATIONSHIP TO ANGINA
PECTORIS*
Warfield T. Longcope, M.D., New York, N. Y.
One might think that the subject of cardiac
pain and coronary artery disease was almost
threadbare, for angina has been talked of and
written about for years and has become so fa-
miliar as to be commonplace. But when a care-
ful search is made for very exact information
concerning the actual cause of precordial pains,
their importance, or indeed their precise relation
to diseases of the heart muscle, the coronary ar-
teries or the aorta, this exact information is
meagre, or incomplete.
Since pain in the region of the heart is a symp-
tom that quickly attracts the attention of the pa-
tient and frequently arouses not only his anxiety
but that of his physician, it behooves us to take
stock from time to time of our knowledge of this
condition ; to realize our limitations in interpret-
ing the symptoms and to add what grains of in-
formation that we may possess in an effort to
elucidate more clearly its causes or its meaning.
Undoubtedly there are many patients who have
severe precordial pain upon exertion and yet have
no organic disease of the heart. This is particu-
larly true of the young adults with irritable heart
or disordered action of the heart. The precor-
dial pain in these patients is not a symptom of
grave circulatory disease threatening life, and
though we appreciate the insignificance of this
pain, we are highly uncertain as to its origin.
The precordial pain of mitral stenosis, that is so
often localized in the apical region has an entirely
different significance, and though it is associated
with an organic heart lesion, it may subside as
Mackenzie says, when auricular fibrillation sets
in and dyspnoea appears on exertion. The pain
of mitral stenosis is no more a warning of sudden
death than is the pain of irritable heart. In
aortitis and particularly that due to syphilis, the
substernal pain which frequently radiates to the
neck or to the left arm is a signal of danger
ahead and these patients may without further
warning drop dead.
It has usually been supposed that the serious
forms of precordial pain were dependent upon
disease of the coronary arteries, for it has often
been found at the autopsy upon patients dying of
•Presented before the Tri-State District Medical Association,
Milwaukee.
[August, 1922
angina pectoris that the coronary arteries w'ere
more or less diseased.
From the time of Huchard, however, the
French have emphasized the importance of dis-
ease of the aorta itself as a cause of angina pec-
toris, and among the English who have contrib-
uted so much to this important subject. Sir Clif-
ford Allbutt upholds most strongly the view that
the common cause of angina pectoris is disease of
the wall of this great vessel.
With the more careful studies of the syphilitic
form of aortitis, which have been made in the last
ten years, our information has been somewhat in-
creased as regards the pain associated with this
affection. We now know from the careful ob-
servations of Mackenzie and Head, that pains
connected with disease of the heart and aorta are
referred through reflex impulses through the
spinal segments to the peripheral nerves, and,
therefore, are distributed to definite regions of
the body which are often far removed from the
seat of origin in the diseased organ. It is also
known that the walls of the aorta, as well as of
the heart, are well supplied with nerves which
when irritated may arouse serious reflex phen-
omena. The physiological studies of Francois
Frank rarely quoted, showed well how parox-
ysms of dyspnoea might follow stimulation of the
root of the aorta in dogs. Thus the anatomical
and physiological mechanisms are at hand, to al-
low of the transmission of stimuli from the root
of the aorta to the spinal cord, and one can read-
ily conceive that some of these impulses might re-
sult in pain.
The pain in syphilitic aortitis is usually sit-
uated high in the chest, beneath the sternum and
sometimes the manubrium. With great fre-
quency it radiates to the left shoulder, the inner
surface of the arm, the forearm, or actually to
the fingers. Occasionally the radiation is up the
left side of the neck, into the jaw or teeth or even
to the face. The attacks are often classic of
angina pectoris and sudden death is not infre-
quent. The fact that the syphilitic process usu-
ally affects the root of the aorta, and often pro-
duces in this situation, narrowing of the mouths
of the coronary arteries has led many to believe
that interference with the coronary circulation
is the direct cause of angina pectoris in syph-
ilitic aortitis. It is indeed difficult in such cases,
to disregard a possible coronary stenosis, but
there is considerable evidence to show that this
is not the cause of anginal pain in all cases of
syphilitic aortitis, for typical cases of angina pec-
toris occur in syphilitic aortitis without the slight-
est involvement of the coronary arteries. In
Journal of Iowa State Medical Society
VoL. XII, No. 8]
Journal of Iowa State Medical Society
315
many cases, however, disease of the aortic valves
gives rise to aortic insufficiency, and it is diffi-
cult under these circumstances to exclude as a
cause of the pain, a sudden stretching of the
wall of the ventricles, which Mackenzie considers
of such importance as a cause of anginal pain.
Although it is difficult to secure proof, the facts
and observations at our disposal suggest very
strongly, that irritation and especially sudden
stretching of the walls of the aorta, as well as the
walls of the chambers of the heart, may result in
disagreeable sensations, varying from slight sub-
stemal oppression to agonizing pain.
Occlusion of the coronary arteries whethe"
slow or rapid is in itself a very serious disorder,
and the recognition of this disease by an analysis
of symptoms and physical signs is of utmost im-
portance, not only because the condition forms
one chapter in the group of anginas, but because
the life of the patient may hang on the diagnosis.
The clinical syndrome that characterizes coron-
ary thrombosis has recently received much atten-
tion and the excellent descriptions of Herrick,
have made many of the symptoms and signs of
this disorder sufficiently familiar to allow of a
probable clinical diagnosis in many instances.
The picture in its typical form, however, is not
common to observe and it, therefore, is import-
ant to add the information that may be gained
from careful studies of such cases, especially
when an autopsy can be obtained, so that our
knowledge of this important disease may be en-
riched. It has seemed to me, consequently, of
value, to bring together a group of such cases for
study and analysis and to present a summary of
the results at this time.
Many of the autopsies and the pathological
work were done by Dr. Von Glahn and some of
the electrocardiograms were collected and an-
alyzed by Dr. Richardson.
From 1913 until July, 1921, there were ob-
served at the Presbyterian Hospital, seventeen
cases of advanced coronary artery disease in all
of whom the final diagnosis was made at autopsy.
Electro-cardiograms were obtained in nine of the
seventeen cases.
From the clinical standpoint the cases are fairly
sharply marked into two groups, namely, those
patients who do not suffer pain, and those who
do have pain. There were only four cases that
were free from pain. The disease in these cases
ran the course of rapidly progressive myocardial
insufficiency.
In the second group of twelve cases, there were
features of special significance which often were
suggestive of some extensive, though rarely sud-
den damage to the heart muscle. In all of them
pain either intermittent or constant and situated
over the precordium and occasionally radiating to
the left side or to the left arm, was a prominent
feature. In only one was there any definite evi-
dences of disease of the heart valves. This was
a case of aortic insufficiency. In three there
were thrombi in vessels other than the coronary
arteries, one case having suffered from gangrene
of the toes due to what was supposed to be throm-
boangeitis obliterans. In four pericardial friction
rubs were heard during the last illness. To il-
lustrate the course of the disease in these pa-
tients, I may briefly review one or two of them.
A gentleman, fifty-four years of age, who had
spent much time in Cuba was admitted to the Pres-
byterian Hospital on June 9, 1921, complaining of
an acute gastric disturbance. He had always been
extremely healthy but twenty years ago after taking
a very difficult and fatiguing horseback ride he had
experienced a sharp and severe pain in the left chest
that momentarily disabled him. From that time un-
til four years ago he had to be quite careful in
walking or riding, for any extra exertion would
bring on an attack of pain. He described the pain as
though a band were drawn about his chest in the
position of inspiration. He otbained relief by rest,
by belching of gas and by holding his chest in the
inspiratory position. For four years he had been
getting progressively worse and his tolerance of exer-
cise had steadily diminished. He had considered
that he was suffering from some stomach trouble
and had consulted many doctors all of whom told
him that they could find no abnormality. The pres-
ent attack set in with violent pain in the epigastrium
at 8:00 o’clock in the evening and immediately after
a meal. It was the most severe he had ever had.
The pain extended laterally to the sides of both
arms. He felt as if he had much gas on the stomach
which he could not belch up. The pain had con-
tinued almost unabated during ten days. The pa-
tient when he arrived at the hospital was in much
pain. He was slightly obese, was sitting up in bed,
was pale, and seemed much prostrated. There was
no cyanosis. There were considerable numbers of
rales at both bases. The respirations were shallow
and slightly increased. The pulse was rapid, 120,
and extremely feeble. The blood-pressure was only
76/68. The cardiac impulse could not be felt. The
heart was enlarged to percussion. The heart sounds
were feeble. There was a gallop rhythm but no
murmur could be heard. There was no hyperesthesia
over the precordial area or over the left arm. The
abdomen was soft and not especially tender. The
liver was palpable below the costal margin. There
was no edema of the extremities. The impression
then, was that this patient had had attacks of angina
pectoris, and was suffering from acute cardiac in-
sufficiency. The possibility of coronary thrombosis
was considered. Digifolin was administered imme-
316
Journal of Iowa State Medical Society
[August, 1922
diately and on continued digitalis therapy, diet and
rest, his condition improved slightly. As the pain
gradually diminished the signs of cardiac insuffi-
ciency appeared. There was edema of the ankles,
enlargement of the liver and fluid in the pleural
cavities. The gallop rhythm was replaced by a
systolic murmur and the blood-pressure rose to
110/80. The subsequent course was characterized by
a progressive cardiac insufficiencj", attacks of dys-
pnoea, and a few days before his death, the appear-
ance of extra systoles. The pulse ranged between
90 and 120. The electrocardiograms showed various
phases of bundle branch block. He died suddenly on
the night of March 25. The history and clinical
course seemed to us to justify the diagnosis of cor-
onary artery disease probably with thrombosis.
The autopsy disclosed the most extreme degree of
coronary arterio-sclerosis with narrowing of the
right artery and complete occlusion 3 cm. from its
origin. The left coronary was calcified, the de-
scending branch was occluded at a distance of 0.5
cm. from its origin and converted into a cord for 3
cm. below this point, while the circumflex branch of
the left was calcified and plugged by a thrombus
mass at its origin from the main stem. The heart
was somewhat enlarged weighing 450 grams. There
was the most extreme fibrosis of the walls of the
ventricle, particularly of the posterior wall of the
left.
This history illustrates the course of events in
those cases in which the disease pursues a long
course, though the terminal and acute illness may
be of comparatively short duration and death it-
self may come suddenly.
There are instances of coronary thrombosis,
however, in which death follows shortly after the
first appearance of symptoms, though in this
series it was rare and occurred in only two cases.
The following is a characteristic example:
A music teacher, forty-four years of age, was ad-
mitted to the Presbyterian Hospital on November
20, 1914, complaining of pain in the pit of the stom-
ach, which he had had for two days. Two nights be-
fore admission, after eating in a restaurant he was
seized with a sudden severe pain in both sides of the
chest. It extended especially to the left and was
more severe on this side. He was somewhat relieved
by drinking hot water and belching. The pain re-
curred off and on since then and at times was ter-
rific. It started in the pit of the stomach and
radiated to the left chest. Recently it had been more
constant but less intense. He vomited the day be-
fore admission. He was in exquisite pain and was
relieved by lying on his back. The patient was
rather a large man and was somewhat cyanotic, and
writhed about in bed. There were a few rales at the
bases of the lungs. The apical impulse of the heart
could not be seen nor felt. The heart was somewhat
enlarged. The sounds were short and sharp. There
was a very short systolic murmur at the apex. The
rate varied and at times 150 to the minute, at others
only 80. The blood-pressure was 98/75. The abdo-
men was soft, but there was some tenderness in the
epigastrium. The liver was just palpable at the
costal margin. The temperature was 102^. On
November 21, though the pain was somewhat better,
his general condition had not improved and the
paroxysms of tachycardia continued. On the 22nd,
the pulse remained persistently at 170 and the elec-
trocardiograms showed auricular flutter. He failed
rapidly, Cheyne-Stokes respiration appeared, he be-
came pale and cyanotic, the chest pain continued,
radiating from the epigastrium across the chest to
the left axilla, his extremities were cold and clammy,
a pericardial friction rub was heard and he died in
collapse on November 26. The illness was short last-
ing only nine days. It was suspected from the acute
onset of excruciating pain with cardiac collapse and
tachycardia and from the later development of a
pericardial friction rub that the patient might have
coronary thrombosis with infarction of the myo-
cardium as a sequel.
The autopsy revealed general arterio-sclerosis with
sclerosis of the coronary arteries of marked degree
causing great narrowing of the lumen in both. In
the descending branch of the left coronary there
was a fresh thrombus about 1 cm. in length which
entirely occluded the lumen. The vessel was besides
markedly sclerotic and even where it was not throm-
bosed the lumen was scarcely permeable. The heart
was enlarged and weighed 675 grams. There was a
fresh fibrinous exudate over the pericardial surface.
The left ventricle seemed to bulge. The cavity was
enlarged and in the apex was a soft friable thrombus.
The wall of the left ventricle corresponding to the
distribution of the descending branch of the left
coronary was thin and in places soft and friable. It
appeared on section to be an infarct.
This case might be used to typify the classical
examples of coronary thrombosis and yet the pa-
tient was really the only one in the group that
presented this picture.
Finally, mention must be made of the single
case of coronary embolus in Group III.
A summary of these seventeen cases, shows
that an occlusion of one or more important
branches of the coronary arteries by a sclerotic
process occurred in six, occlusion by thrombi al-
ways associated with sclerosis in ten, and occlu-
sion by embolus in an otherwise normal coronary
artery in one.
In the last case death occurred almost imme-
diately, and it seems probable from the reports of
occasional instances of rapid and complete occlu-
sion of a left coronary artery which had not pre-
viously been diseased, that death usually occurs
instantly or within a few minutes after this acci-
dent in man.
There were certain features common to the re-
maining sixteen cases.
VoL. XII, No. 81
Journal of Iowa State Medical Society
317
Few patients succumb to this affection before
the age of fifty. Two patients were forty-four
and forty-eight respectively ; eight were between
the ages of fifty and sixty, five between sixty and
seventv, and one over seventy. All but one pre-
sented symptoms of rapidly progressive cardiac
insufficiency, and this one patient died of car-
cinoma of the stomach. In most instances the
pulse was elevated and in many there was some
variety of cardiac irregularity. Occasionally
there was fever and sometimes a moderate leu-
cocytosis. Only two patients gave a positive
Wassermann reaction. In one of these, there
was a typical syphilitic aortitis with occlusion of
the mouth of the right coronary by this process.
From the survey of these cases and a review of
those which have been reported in the literature,
it seems likely that we cannot well separate the
different forms of coronarj'- obstruction in elderly
people, for the symptoms, the signs and the re-
sultant changes in the heart muscle may be the
same whether the occlusion is produced by throm-
bosis or by sclerosis.
Our information concerning the effect of in-
terference with an absolutely normal coronary'
circulation is derived almost exclusively from ex-
periments upon dogs, and according to the recent
work of Porter, of Miller and Mathews and of
Smith, the ligation of one or even two branches
of the coronary artery is not always fatal. Miller
and Mathews tied the ramus descendens sinister
without causing death in any of their dogs, and
Smith in eleven dogs had a mortality of only
9 per cent. The mortality is much higher, how-
ever, when the circumflex branch of the left or
the right artery is tied and was 57.54 per cent in
Smith’s experiments.
In spite of the fact that injections of the cor-
onary arteries of man have shown there are anas-
tomoses between them and that they are not end-
arteries.
It is problematical whether man would sur-
vive as does the dog, sudden occlusion of any
large branch of the coronary system. In the few
cases recorded of embolus to an otherwise healthy
coronary artery, or thrombosis of a large branch
but slightly affected by sclerosis, death has usu-
ally been sudden. These, however, are the very-
rare occurrences, for as a rule, occlusion occurs
in a vessel, the lumen of which has already been
slowly narrowed by sclerosis and one portion of a
vascular supply, already distorted and made ir-
regular by disease is suddenly shut off. Indeed,
one is often amazed, in studying these cases of
coronarv- sclerosis, at the reduction of the coron-
ary circulation, and the serious damage to the
myocardium that is still compatible with life.
We must recognize, therefore, that the disea.se
starts actually years before it is usually recog-
nized. In a few cases, as the sclerosis increases
insiduously, .small branches of the coronary ar-
teries are occluded and even thrombosis may take
place until the damage to the myocardium is so
extensive that the heart muscle at last is unable
to carry on its work and symptoms of cardiac in-
sufficiency supervene. As a rule, the appearance
of these symptoms is rather sudden and unlike
many other forms of heart disease, remissions are
not common and the progress is rapidly down
hill. In these patients there is no preliminary
warning of the coming trouble, such as pain, and
there may not be any distinguishing features to
show that the myocardial insufficiency is depend-
ent upon a diseased coronary circulation.
In another group, there are features of such
special significance that the clinical picture has
attracted the attention of many and especially
through the excellent descriptions of Herrick,
they have been made familiar to us. The onset
of the alarming symptoms is sudden and thougli
the duration of life is short, lasting but a few
days or weeks in most cases, a few patients may
recover. In this group, pain is a significant fea-
ture, and allusion has already been made to the
type; and the frequency with which it occurs in
the precordial area, radiating to the left side of
the chest or in the epigastrium or upper abdomen.
The intensity and situation of the pain on the
epigastrium may even simulate such an acute ab-
dominal condition.
The attack not infrecjuently follows a meal and
as it may be associated with gaseous eructations
or vomiting, is ascribed to some indigestible food.
In many instances, the pain is constant and per-
sistent. The patient is prostrated, frequently
pale, sometimes slightly cyanotic ; the skin may be
cold and he may be sweating. The respirations
are increased and there are usually rales at the
bases of the lungs. The pulse is small and almost
always rapid. In many instances, there is tachy-
cardia which may be either persistent or par-
oxysmal. In the majority of these very acute
cases, the blood-pressure is unusually low, and
the systolic may be below 100. The heart is en-
larged, the apex often difficult to locate, the
sounds are faint, and if they are not too rapid, a
gallop rhythm may be detected or a systolic mur-
mur. Within a day or two of the onset, the signs
of cardiac insufficiency make their appearance.
Quite regularly, as has been emphasized by Lib-
man, the liver is enlarged, and there is tenderness
318
Journal of Iowa State Medical Society
[August, 1922
over it. The rales in the lungs increases, fluid
may accumulate in the pleural cavities, dyspnoea
increases, the extremities become edematous. A
very important sign indicative of acute infarc-
tion of the myocardium, is the appearance of a
pericardial friction rub, often localized and some-
times transient. The importance of this sign has
recently been well brought out by Gorham. Dur-
ing this period there is usually fever of 100 to 103
degrees and there is often a moderate polymor-
phonuclear leucocytosis. In its characteristic
form, the symptom complex is so striking that
it can be recognized without much difficulty.
Death occurs, as a rule, within a few days to i
few weeks, though occasionally patients with
similar symptoms of moderate severity recover.
In the third group, the attack which has just
been described is preceded for months or years
by at least one premonitory symptom. This pre-
monitory symptom is pain. It is often fleeting in
character, sometimes mild, frequently occurs at
irregular intervals, but partakes of the character
of the pain that is experienced during the acute
attack, and is most frequently induced by exer-
cise or occurs after meals. In many instances,
pain is the only premonitor)- symptom but in
others, the pain is associated with slight breath-
lessness or other evidences of myocardial insuffi-
ciency.
It is in this group that an excellent opportunity
is afforded for an early diagnosis, if we had the
criteria at our disposal, and perhaps for the insti-
tution of preventive measures that might pro-
long the cardiac efficiency and the life of the pa-
tient. In a certain proportion of cases, the exam-
ination at this time shows some enlargement of
the heart with perhaps a systolic murmur at the
apex. The radial arteries may be palpable and
there may be other evidences of peripheral ar-
terialsclerosis. In a few instances the blood-pres-
sure is elevated. A small proportion of patients
give a positive Wassermann reaction, though this
would cause one to suspect that the pain was con-
nected with a syphilitic aortitis.
In a very fair proportion of patients, however,
the most careful physical examination does not
elicit any definite signs of disease of the heart,
and it is in this group that it is most difficult to
determine whether or not tlie myocardium has
been damaged by interference with its blood sup-
ply, or if so, to what degree or extent the injury
has progressed.
For a more accurate study of such cases, the
electro-cardiograph has been employed and it has
seemed from recent studies that significant
changes may occur in some of the ventricular
complexes in angina pectoris and coronary throm-
bosis that are indicative of disease of the heart
muscle.
Lewis found that ligation of a coronary artery
in dogs was frequently and rapidly followed by
single extrasystoles arising in one ventricle or the
other. Within one to one and a half hours, there
occurred rapid successions of ventricular extra-
systoles producing attacks of ventricular tachy-
cardia at rates of 300 to 420 beats per minute. In
some instances, the ventricles went into fibrilla-
tions and the dogs died. Smith has repeated
these experiments on dogs, ligating the ramus de-
scendens sinister, the circumflex sinister, the cor-
onaria dextra, and combinations of these three
and has confirmed Lewis’ observations inasmuch
as he finds as an early effect of ligation of these
vessels ventricular and auricular extra systoles
which may be followed particularly after ligation
of the circumflex artei*)" by auricular flutter,
ventricular tachycardia or ventricular fibrillation.
He continued to study the animals that survived,
and described a definite series of changes in the
T wave that he considered characteristic of the
effects of coronary occlusion. These consisted in
an immediate marked exaggeration of the T wave
with its foot point on the R wave and a change
to negativity within the first twenty-four hours.
Later, there was a gradual reversion to its posi-
tive position with a final isolectric or negative
position.
Since the publication of these experiments,
electrocardiograms have been published from a
limited number of cases which were proven to
have coronar)- thrombosis at autopsy, or were
diagnosed as such, from the clinical course of
the disease, and in several instances the curves
have conformed quite accurately with those ob-
tained after experimental occlusion of the coron-
ary arteries. Hermann reported six such cases
with three autopsies. Electrocardiograms made
in four cases, one of which came to autopsy
showed ventricular tachycardia. Robinson re-
ports four instances of ventricular tachycardia in
one of which thrombosis of the coronary arteiy
was proven at autopsy, while in the remaining
three it was suspected.
Previously Herrick had recorded a case of cor-
onary thrombosis with autopsy, in which electn>-
cardiograms showed changes in the ventricular
complex, and in the T wave that corresponded al -
most exactlv to those reported by Smith, and
Pardee later, published one case without autopsy,
presenting the same type of electrocardiograms.
Pardee felt that it was an electrocardiographic
sign which is characteristic of coronar)- thrombo-
VoL. XII, No. 8]
Journal of Iowa State Medical Society
319
sis. Willius in a recent electrocardiograph study
of 155 cases of angina pectoris, found eighteen
cases or 11.6 per cent had the electrocardio-
graphic alterations in the T wave described by
Smith. In many other cases, abnormal electro-
cardiographic curves were obtained, and among
these twenty-two cases had aberrant Q. R. S.
complexes in all leads which conformed to the
type obtained in animals or patients with bundle
branch block. He, however, lays considerable
stress on the significance of alterations in the T
wave as an indication of myocardial damage.
A study of the electrocardiograms of nine of
our cases that were proven at autopsy to have
coronarA' occlusion adds rather inconclusive evi-
dence to the cases that have already been pub-
lished. In four cases there was auricular flutter.
One of these patients had thrombosis of the
descending branch of the left coronary artery,
and was the man who was described as dying
within nine days of the onset of his acute pain,
the other showed thrombosis of the descending
branch of the left coronary arteiy'. All showed
extensive lesions in the myocardium supplied by
these vessels. In two of these cases the flutter
ceased and the rhythm became normal before
death. In none of them were there significant
alterations in the Q. R. S. complex and in none
were there changes in the T wave that corre-
sponded to those described by Smith and others.
Two cases, both with thrombosis of the de-
scending branch of the left coronary artery,
showed electrocardiograms in which the Q. R. S.
complex was distinctly abnormal. In its widen-
ing, in its small size, and in its notching in all
leads, it presented the appearance which has been
described by Oppenheim and Rothschild and
others and which is considered indicative of a
bundle branch block. In three cases, one of oc-
clusion of the right coronary, one of occlusion of
the circumflex branch of the left with partial oc-
clusion of the right and one of thrombosis of the
circumflex branch of the left, the electrocardio-
grams showed no significant abnormalities except
those alterations in the deflections of the R wave
that are indicative of left ventricular preponder-
ance. It is obvious, therefore, that many cases of
coronary artery- thrombosis and occlusion may
occur, without the production of ventricular
tachycardia or the detection of those alterations
in the T waves that are so frequently encountered
after experimental ligation of these arteries in
dogs. When these abnormal electrocardiograms
are obtained they are undoubtedly a sign of value,
but they may be absent in the most characteristic
In conclusion, therefore, I may say that sudden
stoppage of the circulation in one or the other
coronary artery^ which is otherwise normal, prob-
ably leads to immediate or fairly sudden death,
possibly from fibrillation of the ventricles.
Thrombosis usually but not invariably-, occurs
in arteries that are previously diseased and nar-
rowed by sclerosis.
Occlusion either by thrombosis of sclerosis un-
der these circumstances may be compatible with
life for varying periods of time, though death
when it comes is usually sudden. In a small
group of cases, the disease pursues its course as
a rapidly progressive cardiac insufficiency with-
out features of particular note. But in the great
majority of cases, there are significant symptoms
and signs that frequently allow of a fairly accur-
ate diagnosis. Most important of these are pain
often with a particular radiation, the appearance
of transient pericardial friction rubs, often asso-
ciated with the acute onset of myocardial insuffi-
ciency and various forms of tachycardia and car-
diac arrhythmia, all occurring in an elderly per-
son usually without signs of valvular heart dis-
ease. Unfortunately, there does not seem to be
anyone electrocardiographic sign that occurs in
all cases.
BIBLIOGRAPHY
Herrick, J. B.. J. A. M. A., 1912, lix, 201.5.
Herrick, J. B., J. A. M. A., 1919, Ixxii, 38'.
Herrick and Nuzam, F. R., Angina Pectoris, J. A. M. .A., 1918,
Ixx, 67.
Porter, W. L., J. Phys., 1894, xv, 121.
Miller, J. L., and Mathew, S. A., Arch. Int. Med., 1909, iii,
page 476.
Smith, F. M., Arch. Med., 1918, xxiii, 8.
Libman, E., Trans. Ass’n. Amer. Phys., 1919, xxxiv, 138.
Gorham, L. V., Albany Med. Annals, 1920, April.
Lewis, T., Heart, 1909, 1910, 1, 43.
Hermann, S. R., J. Missionary State Med. Ass’n, xxii, 406.
Robinson, S. C., Heart, 1921, viii, 59.
Herrick, J. B., J. A. M, A., 1919, Ixxii, 387.
Pardee, H. E. B., Arch. Int. Med., 1920, xxvi, 244.
Willius. F. A., Arch. Int. Med., 1921, xxvii, 192.
Oppenheimer, B. S. and Rothschild, M. A., J. A. M. A., 1917,
Ixix, 429.
SYPHILITIC AORTITIS, A CAUSE OF
SUDDEN DEATH*
L. R. Woodward, M.D., Park Hospital,
Mason City
The reason for this paper is that two cases of
sudden death due to syphilitic aortitis have re-
cently’ come to my attention and some features of
them seemed to be worthy- of being reported. In
one case the man was sick enough to consult a
physician, and the condition was strongly sus-
pected, but he died suddenly before examination
was completed and the condition was proven bv
autopsy. In the other case, the man had some
cases.
•Read at Austin Flint-Cedar Valley Medical Society, July 20, 1921,
320
Tournal of Iowa State Medical Society
[August, 1922
fiain for which he consulted a physician some
months previously, but he died very suddenly, and
the condition would not have been suspected if a
post-mortem examination had not been made. In
both cases, the syphilitic aortitis had progressed
to the stage of aneurysm formation, and death
was due to rupture of the aneurysm. The reason
I have chosen to consider this paper as syphilitic
aortitis rather than aneurysm, is that the primary
disease was syphilis, and aneur\'sm merely the
final stage of the process. Ordinarily we think
of apoplexy and heart disease as causes of sudden
death, but syphilitic aortitis is quite as common.
I have endeavored to find definite statistics to
give in regard to the frequency of its occurrence,
but have not been able to get complete data on it.
That it has been noticed, is evidenced by the fact,
that Draper^ in 1895 published a paper entitled
“Sudden Death by Rupture of Thoracic Aneurysm
Previously Unrecognized.” DuBray^ makes the
remark, that in the experience of pathologists
making post-mortem examinations of coroners’
cases, ruptured aneurysm stands high in the list
of causes of sudden death. The exact percentage
of the population who are infected with syphilis
no one knows. Schrumpf^ quotes figures to show
that 5 per cent of syphilitic males have changes
in the organs of circulation, and over three-
fourths of these are in the aorta. I am inclined
to think his figures are too low, for syphilis is
primarily a disease of blood-vessels, and being
bourne by the blood, the blood-vessels are in-
fected through the vasa-vasorum. The aorta at
the autopsy table is found more frequently in-
fected than any other vessel, and it is most com-
monly affected in the parts nearest the heart.
Senile aortitis is more common in the descending
abdominal aorta. The pathological processes of
syphilitic aortitis, as it involves the media of the
aorta, beginning about the vasa-vasorum have
been very carefully worked out and is specific for
the disease. Spirocheta pallida has been isolated
from the lesions by many reliable workers. Ac-
cording to ArnokP, in an analysis of 1829 cases,
rupture was the cause of death in 53 per cent of
cases. Death in the remainder of the cases, was
due to pressure effects on surrounding tissues, as
nerve, blood-vessels, or bones. From the vital
statistics of the U. S. Census Bureau, it is found
that diseases of the arteries stands eighth in the
list of causes of death, causing 19,055 deaths out
of a total of 1,068,932 deaths in the registration
area during the year 1917. Apoplexy is sixth,
with a total of 62,431, but unless the cause was
proven in all cases by autopsy, many of these may
have been due to a ruptured aneurysm, for most
physicians will give either apoplexy or heart fail-
ure as the cause of sudden death rather than rup-
tured aneur}-sm, and by necropsy it is found that
over 50 per cent of ruptured aneurysms that are
found, have been incorrectly diagnosed ante-
mortem. Statistics thus show that over half of
patients known to have an aneurysm die suddenly,
and diseases of arteries stands high among the
list of causes of death. Unfortunately, I have
not been able to get figures to show the exact per
cent of sudden deaths that are due to ruptured
aneurj'sm.
A point I wish to emphasize is, that all writers
are agreed that the most favorable time for treat-
ment of syphilitic aortitis is early. When it has
reached the stage of aneurysm formation very lit-
tle can be done, but during the stage of atheroma,
it responds to vigorous anti-syphilitic as well as
any other type of syphilis. \\Ten one considers
that it is a disease of the two best decades of life,
thirty to fifty years, one realizes that it is a sub-
ject of more vital importance than cancer. Sta-
tistics are not wholly reliable, but most investiga-
tors have found positive evidence of syphilis in
60 to 85 per cent of all cases of aneury^sm. Fig-
ures that have been collected, show that in fatal
cases of syphilis, aneurysm occurs in 30 per cent,
as shown by autopsy findings. Patients who re-
ceive inadequate treatment for syphilis, show up
after a few years with definite evidence of aortic
disease. I wish again to repeat the necessity of
adequate treatment of syphilis early to prevent
this common and incurable complication of syph-
ilis. Power^ reports the results of wiring, which
is the only treatment that offers any hope at all.
Sixteen cases were wired one or more times with
only two patients living at the end of ten years.
Some were relieved of pain temporarily, which
is the thing they sought relief for, but several died
within a few months of rupture, even though it
was found at autopsy that the sacs had been
filled with thrombi. One of the cases that came
under my observation died of rupture suddenly,
though the sac had spontaneously filled with a
thrombus. Case reports follow. I am indebted
to Dr. George ]\I. Crabb for the findings in case 1.
Case 1. Mr. R. — Patient came to the office late in
the evening so that a complete history and examin-
ation was not secured. This was on February 5, 1921.
He complained of cough and shortness of breath on
exertion. He had noticed that he had not felt well
since Christmas, 1920. Soon after he entered the of-
fice he coughed, and it was the typical brassy cough
of aneurysm. Immediately he was examined for
tracheal tug and a very pronounced one was found.
Temperature was 98.5. There was a unilateral swell-
ing of the chest on the left side, but it was not pul-
VoL. XII, No. 8]
Journal of Iowa State Medical Society
321
sating. There was dullness on percussion over the
left upper lobe. .Aortic dullness was not increased
in width. No thrill or bruit could be heard over the
aorta. Under the fluoroscope, the aorta was seen to
be definitely wider than normal, but no pulsating sac-
cular enlargement could be seen. A provisional diag-
nosis of aortic aneurysm was made, and he was ad-
vised to return for a complete examination. He felt
better the next day and he did not come back.
On February 8, just three days later, the coroner
was called to investigate a sudden death. He found
that this man had died suddenly. While dressing in
the morning he had a profuse hemoptysis and bled
to death. The necropsy findings follow.
The left lung has red hepatization. It is filled with
blood, does not crepitate and cuts with increased re-
sistance. The right lung ciepitates anteriorly but
posteriorly it is filled with blood.
The pericardial sac contains about 6 ounces of
stratv colored fluid.
The aortic valves are thickened and have yellow
patches on them. The intima of the aorta is studded
with yellow patches. There is a saccular aneurysm
of the arch of the aorta where it crosses the left
bronchus. This sac communicates with the left
bronchus by an opening about one-half by three-
fourths of an inch.
The remainder of the examination was negative.
The Wassermann on the pericardial fluid was posi-
tive, giving a four plus reaction.
Case 2. Mr. B. — The coroner was called early in
the morning on Tune 13, 1921, to investigate the death
of a man who was found dead in his garden. It was
found that he had fallen backward while hoeing po-
tatoes. There was no blood on the ground and no
bleeding from the nose or mouth.
A good history could not be obtained, but it was
learned that he suffered severely from neuritis over
the left shoulder and the left side of the neck for
about six weeks last autumn. He had never fully re-
covered from this neuritis, but it had not been caus-
ing him so much pain this spring. He worked in a
brick and tile plant until February of this year when
he was laid off, due to the plant closing down. He
had been doing his own garden work all spring.
This death would have been reported as apoplexy
if the coroner had not ordered an autopsy, the find-
ings of which follow.
Necropsy Report
This is the body of an adult white male, approx-
imately six feet in height and weighing approxi-
mately 175 pounds. The head is covered with dark
hair streaked with grey. There is the usual posterior
lividity of dependent parts but there are no other
unusual marks on the surface of the body.
On opening the body the subcutaneous fat is found
to have a thickness of one-half an inch in a mid-line
incision at the umbilicus. There is no free fluid in
the abdominal cavity. There are no adhesions and
all abdominal organs appear to be normal.
On removing the sternum a mass the size of a
lemon is found about the great vessels of the neck
beneath the right sterno-clavicular joint. There are
no adhesions and no free fluid in the right pleural
cavity, and the right lung appears to be normal. The
left pleural cavity contains approximately three
quarts of fluid and clotted blood. When this is re-
moved the cavity is found to be free of adhesions,
and the lung appears to be normal except for a mass
the size of a lemon at the hilus.
On opening the pericardial sac the heart is found
in firm systole. There are no adhesions or free fluid.
The structures of the neck are divided and the con-
tents of the thorax reflected. On opening the trahea
it is found to contain some tobacco but no blood at
all. There is no redness of the mucosa at any place,
and no increase of mucus. The esophagus and vena
cava appear normal. There is moderate anthracosis
of the tracheo-bronchial lymph nodes. The lungs
crepitate well everywhere except the right apex
which cuts with increased resistance and has some
fibrosis.
On opening the heart, there is found the usual
post-mortem clot in the right ventricle. The myo-
cardium appears normal as do all the valves.
On opening the aorta the aortic valves appear
normal but a marked atheroma of the aorta is found
beginning immediately above the valves and involv-
ing the ascending aorta, arch and descending thoracic
aorta more than the abdominal. There are many
raised yellow plaques with depressed puckered areas
between. There is no calcification. There is a sac-
cular aneurysm of the innominate artery about the
size of a small lemon, which communicates with the
aorta by an opening about one inch in diameter. It
is entirely filled with a laminated thrombus which
falls out when the aneurysm is opened. The right
subclavian and common carotid arteries arise from
the sac. Another saccular aneurysm is found in the
descending aorta at the level of the hilus of the lung.
It is about the same size as the first one and its con-
nection with the aorta is about three-fourths of an
inch in diameter. Opening it, it is also found to be
filled with a laminated thrombus. On the anterior
surface where it comes in contact with the hilus of
the left lung there is a rent about one inch long.
The wall is thin as paper at this point.
The liver is normal in size and appearance. There
are no scars on its surface and it cuts with no in-
creased resistance. Cut surface is normal in color.
The spleen is normal in size and has no scars or in-
farcts. Resistance when cut is normal and the pulp
on the cut surface has a normal appearance. All the
other abdominal organs appear normal.
Anatomic diagnosis; Moderate anthracosis of
lungs and tracheo-bronchial lymph nodes. Slight fi-
brosis of right apex. Syphilitic aortitis with atheroma
and aneurysm formation and thrombosis of aneurys-
mal sacs. Rupture of aneurysm of descending thor-
acic aorta with hemorrhage into the left pulmonary
cavity.
Cause of death — Ruptured aneurysm due to syph-
ilitic aortitis.
322
Journal of Iowa State Medical Society
[August, 1922
Conclusions
Diseases of the arteries stands high in the list
of the causes of death, and among these aneurysm
is one of the most important.
Over half of patients known to have an an-
eurysm have died suddenly, and none of them
have lived long after it was discovered.
Among the causes of sudden death, aneurysm
stands high, and if all persons who die suddenly
were examined post-mortem, a much greater inci-
dence would be found for over half of aneu-
rysms discovered post-mortem, have not been
known to exist ante-mortem.
Aneuiy^sms are due in a great majority of cases
to syphilitic aortitis.
BIBLIOGRAPHY
1. Draper. F. W. : Sudden Death by Rupture of Thoracic
Aneurysms Previously Unrecognized. Boston Med. and Surg.
Jour. January, 1895, cxxxii, 245-249.
2. DuBray. E. S. : Saccular Aneurysm of the Descending
Thoracic Aorta with Direct Rupture into the Lower Lobe of the
Left Lung and the Left Pleural Cavity. The Am. Jour, of the
Med. Sci. March, 1921, clxi, 407.
3. Schrumpf: Arch. f. Dermal, u. Syph., 1919, cx.xvi, part 3.
4. Arnold, H. D.: Cause of Death in Aneurysms of the
Thoracic Aorta Which Do Not Rupture. Report of Five Cases.
The Am. Jour, of the Med. Sci. 1902, cxxiii, 72.
5. Power, Sir DeArcy; The Palliative Treatment of Aneurysm
by Wiring with Colt’s Apparatus. The Brit. Jour, of Surg., July,
1921, ix, 27.
Park Hospital Clinic, Mason City, Iowa.
THE CAUSES OF FAILURE OF OPERA-
TIONS FOR CHRONIC APPENDICITIS*
Charles J. Rowan, M.D., F.A.C.S., Iowa Citv
The removal of the appendix because of a diag-
nosis of chronic appendicitis is one of the most
frequent procedures of general surgery. Be-
cause it can be easily and safely removed; it
would seem that the operation should be followed
by a cure in practically all cases ; but the investi-
gations of surgeons, who have carefully followed
up their cases, show that the results can hardly
be considered to be as satisfactory as it would
seem they should be.
In 1916, Connell reported that among 212 pa-
tients operated on by him during the preceding
seven years, there were forty-eight who failed to
get relief of symptoms. He used the tenn,
“pseudo-appendicitis” in connection with these
failures, and especially warned against advising
operation for chronic appendicitis in patients who
had chronic constipation, enteroptosis and neu-
rasthenia. Last year Gibson reported the result
of his investigation of 555 cases, which had been
operated on during the preceding six and one-
half years. He received 426 replies to his letters
*Read before the Seventieth Annual Session. Iowa State Medical
Society, Des Moines. Iowa, May 11, 12. 13. 1921.
of inquir}’. He divides the results into excellent,
satisfactory and unsatisfactory ; and finds that
102 cases should be reported as unsatisfactory.
I have had “follow’ up” letters sent to the pa-
tients operated on in the surgical service of the
University Hospital during the years 1918 and
1919, in whom the diagnosis was chronic appendi-
citis. Patients who had other recognized patholog-
ical abdominal or pelvic conditions were not in-
cluded in this list. The total number of cases was
121, and from these patients, we received 94
replies. I have divided these replies under the
headings, cured, improved and unimproved; and
find that sixty-six have been cured, tw’enty are to
be classed as improved, and eight as unimproved.
Among the improved, we include those who re-
port themselves as better, but still having consti-
pation, or vague pains at times or other indefinite
symptoms. There w^ere no deaths in this series,
and no complication more serious than a stitch
abscess, except in one patient, w'ho developed a
post-operative pneumonia, which ran a short and
mild course. There were fifty-five males and
thirty-nine females in this number, which is as it
should be, since it has long been recognized that
appendicitis is more common in the male.
Among the cured, forty-two were males and
tw’enty-four females. Among the improved, nine
w’ere males and eleven females, and among the
unimproved were four males and four fertiales,
showing that the prognosis as to cure, has been
much better in the male patients.
\Ve have always regarded the history of a for-
mer acute attack as an important diagnostic
point in chronic appendicitis, and we find that in
our ninety-four cases, there w’ere sixty-eight who
gave a history of acute attacks at some previous
time ; and tw'enty-six who did not give such a his-
tory. Among the cured cases, fifty-two gave a
history of an acute attack w’hile thirteen did not.
Among the improved cases, eleven had had acute
attacks and nine had not, and among the failures,
four admitted acute attacks and four did not. We
learn from this that the prognosis as to cure, is
much better w’hen there is the history of a former
acute attack.
In the operation reports, it is found that the
appendix is described as definitely pathological
in eighty-nine cases ; and as doubtful or showing
no pathological change in five cases; and of these
five cases, one is listed in the improved column
and four in the unimproved. This shows that
nineteen out of twenty improved cases, and four
out of eight of our unimproved cases show’ed
pathological changes in. the appendix, and still
were not cured by the operation.
VoL. XII, No. 81
Journal of Iowa State Medical Society
323
In all patients who come to us complaining of
chronic appendicitis, and where the history and
findings are not completely typical, the diagnosis
is practically made by exclusion plus the direct
evidence of a diseased appendix. A patient
without history of an acute attack, is regarded
as atypical, and operation is not advised, unless
the symptoms are very definite and characteristic.
If the patient complains of gastric symptoms;
while we realize that hyperacidity, pylorospasm
and epigastric tenderness may be caused by
chronic appendicitis, we do not admit it as the
cause in any individual case until gastric analysis
and x-ray series have been negative, and even
then, we make an exploratory rather than the
muscle splitting incision. It is now generally rec-
ognized, that chronic appendicitis bears an im-
portant etiological relation to gastric ulcer and
cholecystitis, and we find them frequently co-
existent. By observing these precautions, many
gastric and duodenal ulcers and cases of cholecy-
stitis have been found in patients with chronic
appendicitis, and these cases are not included in
this series, where, if the appendix only had been
removed, they would have been found added to
the number of failures.
In like manner, if there is anything in the
character, location, or reference of the pain,
which suggests the kidney or ureter as a possible
explanation of the condition ; we are not satisfied
that a negative urinalysis excludes the kidney or
ureter, but refer the patient for x-ray examina-
tion. cystoscopic examination and pyelography, if
the urologist thinks it indicated. We realize that
in chronic appendicitis, there may be found a
slight increase in the number of leucocytes in the
urine, but we believe that their presence puts the
burden of proof on the appendix, and on the other
hand, it is well known that pathology in the kid-
ney or ureter, may produce symptoms, while ex-
amination of the urine, shows it to be normal.
By referring such patients to the urologist, even
in the presence of normal urine, we have been led
to refuse operation for chronic appendicitis in
several cases, where if the appendix had been re-
moved, we would have had to add to the number
of failures. •
In dealing with pronounced neurotics, it is
often difficult to come to a definite conclusion as
to diagnosis. It is perfectly true, that a neurotic
yiatient may have chronic appendicitis, but on the
other hand, such a patient, by' complaining of
vague pains, perhaps especially located in the
right, lower quadrant, and accompanied by an in-
definite tenderness, may easily lead one to make
a diagnosis of chronic appendicitis, when it is not
j>resent; and again, the removal of a chronically
diseased appendix in a patient who is decidedly
neurotic, is very likely to disappoint in the
amount of improvement which follows, and may
fail to give any relief whatever. Operations for
psychic effect have long since proven their worth-
Tessness. Patients with mucous colitis, even if
they have pronounced tenderness, in the region
of McBurney’s point, wdll generally fail to be
benefitted by an appendectomy, and this also ap-
plies to patients with marked visceroptosis.
In the cases reported as improved, it is diffi-
cult as a rule, to explain why recovery has not
been complete. Constipation is complained of
by many of these patients, and it is possible that
in some of them, it was the cause of the appen-
dicitis, and that the removal of the appendix has
naturally failed to relieve it. In others, it is pos-
sible that being somewhat neurotic, they are
bothered by the scar enough to complain of pain.
In others, there are undoubtedly accompanying
minor conditions, such as moderate enteroptosis,
pelvic displacements, etc., which still causes some
discomfort ; and in some cases, adhesions may be
the explanation for incomplete relief.
Gibson has noted a very' marked improvement
in his results recently, and is impressed by the
fact, that this improvement has occurred since
iodine was discontinued in the preparation of the
patient. He now uses 5 per cent picric acid in
95 per cent alcohol, and believes, that although
its antiseptic action is as strong as tincture of
iodine, and its penetrating power as great, it is
less irritating to skin and peritoneum, and that
peritoneal adhesions are not nearly so likely to
occur following its use as a skin antiseptic. The
report of such a reliable observer, should carry
considerable weight, and we have recently begun
the use of picric acid in the preparation of the
abdomen for laparotomies.
After a careful study of the hospital records of
the eight failures, we have concluded that three
patients had gastric ulcers at the time of the
appendectomy, and that this accounts for the
failure in these three cases. They' were males
with gastric symptoms and findings on gastric
analysis or x-ray' examination, which pointed to
ulcer. Exploratory incisions were made in these
cases ; and ulcers could not be demonstrated at
the time of operation. Following our rule, which
is not to make a gastroenterostomy unless dis-
tinct evidence of pathology' is found in stomach
or duodenum, we only' removed the appendices in
these cases, one of them being distinctly patho-
logical, and the other two doubtful. The persist-
ence of the symptoms has convinced us that the
324
Journal of Iowa State Medical Society
[x\uGUST, 1922
ulcers are still making trouble. We are still of
the opinion, that the proper treatment in these
cases, where the ulcer is probably present, but
cannot be demonstrated, is to remove the ap-
pendix and advise medical treatment of the ulcer,
hoping that the removal of a diseased appendix,
which may have caused the ulcer, will aid in ob-
taining a medical cure. We do not think that a
gastroenterostomy should be lightly undertaken
in the absence of evident pathology, because in
such cases, it is likely to do more harm than
good. In one male patient with gastric symp-
toms, but negative x-ray and gastric analysis find-
ings, an exploratory operation failed to show any
jiatholog}' in gall-bladder, stomach or duodenum,
but did show a very evident chronic appendicitis,
for which the appendix was removed. The pa-
tient reports that he is still having the same symp-
toms. W'e feel that he may have a gastric ulcer
or a strawberry gall-bladder, which was not rec-
ognized at the time of operation.
One patient was a hysterical girl, whose badly
diseased appendix was removed without benefit
to her. The explanation of a failure in her case,
is the hysteria. One female patient had a pro-
nounced visceroptosis, and the only pathology
found in the appendix, was a kink at its middle.
The appiendix was removed, but no improvement
resulted, nor was it to be expected. In one fe-
male patient, with a typical history, in whom a
diseased appendix was removed through a muscle
splitting incision, no improvement followed, and
we are at a loss to explain the failure, unless it
be, that additional pathology was present in the
abdomen, and was not discovered, because a mus-
cle splitting instead of an exploratorv" incision
was made.
In another female patient, where a diseased ap-
j)endix was i^emoved through an exploratory in-
cision, we are not able to account for the im-
provement being so slight as to cause her to be
listed among the failures.
After a careful study of this series of cases, we
must admit that the results of operation for
chronic appemlicitis in our hands, are not satis-
factory, and that there is considerable room for
impro\ement. In attempting to secure better re-
sults, we believe that the following points are o^
great importance.
1. These patients should have more careful
examination, and often more prolonged observa-
tion, especially if the condition is not in every
way typical.
2. Xo patient should be regarded as having
typical chronic appendicitis unless a history of a
former characteristic, acute attack is obtainable.
3. Extra care and consideration should be
used before advising operation in neurotics, es-
pecially those with colitis or visceroptosis.
4. More exploratory incisions should be used
in preference to the muscle splitting incision, and
always in atypical cases, and the exploration
should not end with the discovery and removal of
a diseased appendix.
5. Believing that a considerable amount of
trouble complained of after operation, may be
due to adhesions, we regard the suggestion of
Gibson as valuable, and will try out picric acid
instead of iodine in the preparation of the site of
operation.
Discussion Dr. Rowan’s Paper
Dr. Oliver J. Fay, Des Moines — I am very
strongly of the opinion that more real benefit comes
from the analysis of our work and a free and frank
confession of the failures, than can come from any
other discussion, and this is particularly true as
regards the subject of appendicitis. It is now some
thirty-three years since the appendix was first at-
tacked by the surgeon, since the diagnosis of an in-
fection of the appendix was first made and an oper-
ation planned for its removal. During these thirty-
three years, the technic has been developed to such
an extent that the mortality from laparotomy for
the removal of a chronic appendix is practically nil,
as Dr. Rowan has shown in his series of cases, in
which he had no deaths. The trouble, I think, as
exemplified in this report on Dr. Rowan’s patients,
is that while operation does not fail to cure their
appendicitis, in many cases it does fail to cure the
complications which e.xisted along with the appen-
dicitis. As an example, the hysterical girl may have
an acute appendi.x; appendectomy will cure the ap-
pendicitis but not the hysteria. And that is one of
the things we should all be very careful about — not
to overlook the fact that the neurotic patient, like
any other, may have typhoid, ma}' have pneumonia,
may have an acute appendi.x, but removal of the ap-
pendix, or recovery from pneumonia will not cure
the hysteria. This accounts for some of the failures
following appendectomy. In three of Dr. Rowan’s
cases there was evidence of gastric ulcer, which
would probably not be cured by removal of the ap-
pendix. It would seem to me that Dr. Rowan has
established a very safe foundation when he rules out
of the category of chronic appendicitis all cases
which do not give a history of an acute attack. Did
I understand this correctly. Doctor?
Dr. Rowan — I said that a patient without the his-
tory of an acute attack is regarded as atypical, and
that operation is not advised unless the symptoms
are definite.
Dr. Fay — If the appendix is the cause of the trou-
ble, in other words if the diagnosis of appendicitis
is correct, removal of the appendix should cure that
particular condition. If there is a chronic appendi-
citis plus a neurosis, or plus any one of the various
VoL. XII, No. 8]
Journal of Iowa State Medical Society
325
pathological conditions of the bowel which are com-
monly termed colitis, appendectomy will not neces-
sarily relieve the complicating or associated path-
ological conditions, and the end results will not be
what we had hoped. There is now no excuse what-
soever for doing an exploratory operation until a
definite diagnosis has been made, or — let me put it
another way — until a thorough attempt has been
made to reach a definite diagnosis. Twenty years
ago it may have been justifiable to open the abdo-
men, look about to see what one could find, and,
fortunately for the surgeon, the appendix was usually
present and its removal would justify his fee. The
thorough work which has been done on Dr. Rowan’s
cases points the way to elimination of most of the
failures which come from operating on an incorrect
diagnosis; the cooperation of the medical depart-
ment with all its varied activities, and the enthusias-
tic appreciation by the chief of that department of
the value of personal analysis and observation has
reduced failures to the minimum. I believe that if
all possible care is taken to rule out all the various
conditions which Dr. Rowan has enumerated, and
the diagnosis of chronic appendicitis is reached only
after this process of exclusion, our failures following
appendectomy wdll be less. In regard to the use of
iodine, I am not so sure. It seems to me that there
were quite as many failures in the old day when soap
and water only were used as there are with the use
of tincture of iodine. If there is any virtue in the
use of picric acid in so far as the prevention of post-
operative adhesions are concerned, then I am heart-
ily in favor of its use.
S. A. Spilman, Ottumwa — This is an important
question for discussion, because if you cannot find
anything else the matter with the patient nowadays
you generally can find something wrong with the
appendix, in your mind. The one particular point
in this paper that should impress us is the importance
of taking a little more time to investigate our cases;
not send a case of supposed chronic appendicitis to
the hospital to be operated the same night, but take
our time.
Dr. John F. Herrick, Ottumwa — I want to empha-
size possibly a little more the condition of viscerop-
tosis as a cause of pain, leading us in some instances
to believe that a chronic appendicitis is present.
More failures have come to my attention in which
there is a ptosis than from any other one cause.
You may know that there is a ptosis, and yet not be
certain that this is the cause of the symptoms. If
you put your patient to bed for three or four days
and the symptoms disappear, j'ou may almost cer-
tainly figure that the condition is not chronic ap-
pendicitis, and then, by careful examination, in a
large majority of these cases you will find that you
have a ptosis, proper care of which will relieve the
patient and cure the supposed chronic appendicitis
without operation. Therefore where differential
diagnosis cannot be made it is well to give those pa-
tients rest for a few days and thus help to eliminate
a condition that is not due to the appendix.
Dr. Donald Macrae, Jr., Council Bluffs — First let
me say that I would very much dislike to have the
members go away from here with the idea that in a
case of acute appendicitis we should not rush into
the abdomen and operate at once, but wait until the
next day. We all know that acute cases should be
rushed in and operated immediately. There is no
doubt that many lives are saved by immediate oper-
ation provided the case has been properly diagnosed.
I am not talking about visceroptosis or gastric ulcer,
but about the acute gangrenous appendix. If I see
one of these cases in the night I operate before day-
light, and I think that is the proper thing to do.
Therefore I do not wish the impression to go out
that we will wait for people to die as I fear may be
gained from the doctor preceding me. The cases
of which Dr. Rowan speaks belong to the chronic
type — the type that bothers us, the indefinite abdo-
men, in which we throw up our hands immediately
on hearing the history, send for x-ray pictures and
gastric analyses. The roentgenologist is at a loss
and sends us word that he thinks the condition is
probably appendicitis, with the result that we per-
haps take the appendix out following the advice of
the x-ray man, which I think is wrong. You should
make thorough physical examination, at the conclu-
sion of which, if you have experience, you will know
whether or not the condition is appendicitis. Then
you should seek to verify your findings through lab-
oratory and bacteriological reports, but do not let
these influence you to a point beyond your own com-
mon sense. Have respect for the opinion of the lab-
oratory man, the bacteriologist, etc., but do not let
their reports sway your best judgment in the case.
Referring to the muscle-splitting operation, the es-
sayist states that in certain classes of cases he will
make exploratory incision, and in another class do
the muscle-splitting operation. I want to say that
I have never been able to be dead sure even in a case
of acute appendicitis just what complications we
might find. The fact of having had several cases in
which gastric ulcer complicated the situation, led me
to determine several years ago that the muscle-split-
ting operation should not be done. When we have
a chronic condition of the appendix we should make
our incision in such a way that we can examine the
stomach, tubes, ovaries, etc. In an acute case that
occurred a number of years ago I was up against one
of these muscle-splitting operations, having to do a
considerable amount of mutilation of the abdominal
wall before I got out; since then I have abandoned
the procedure. The rectus muscle separation is
ideal in every way.
Dr. F. L. Nelson, Ottumwa — In regard to the
acute appendix, I do not think there is any question
but this should be operated on very promptly. How-
ever, the acute condition should not be considered in
connection with the paper under discussion. When
Dr. Spilman spoke of proper investigation of the
case, he, of course, referred to chronic appendicitis.
Failure in our cases of chronic appendicitis is in-
variably a question of diagnosis. In any case that
326
Journal of Iowa State Medical Society
[August, 1922
has never had an acute attack I do not think you will
find a great amount of trouble in that appendix. It
is rather an unusual thing. The question of viscerop-
tosis, which is very important, has been well brought
out by Dr. Herrick. A short time ago we had occa-
sion to discuss this problem together in a case in
which we were associated. The patient had been
away from work for six weeks, with no improvement,
although he had never had an acute attack. His case
had been very carefully worked out, then we oper-
ated on him and secured result, which is rather un-
usual with these indefinite symptoms where only an
appendectomy is done. One more point in connec-
tion with differential diagnosis is your history. One
case was operated on for chronic appendicitis — no
result. On taking a careful history it was found that
this man had had a fall several years previous!}', ever
since there had been pains on his right side and very
typical over ^IcBurney’s point. Some enthusiastic
surgeon operated on him without giving the history
due consideration. It was found that he had a
slightly prolapsed kidney on the right side. He was
cystoscoped and ureter catheterized and after some
manipulation the catheter w'as passed through the
ureter. The patient was promptly cured. In other
words, he had a kink in the ureter. If that had
been done in the first place he would not have lost
his appendix.
Dr. Rowan — I think Dr. Fay and myself are very
well agreed in our idea of the dependence of chronic
appendicitis on acute attacks. I believe that in prac-
tically every case where we find a real chronic ap-
pendicitis, that appendix has at some time been
acutely inflamed, and I would have put it a little
stronger in the paper except for the fact that I have
quite frequently found in an appendix at the time of
operation such gross pathology as to indicate that
the patient certainly must have had an acute attack
at some time, and still the most careful questioning
of the patient failed to bring out that history. So we
might still think that the acute condition had been
present in practically every case of chronic appendi-
citis, and yet this cannot be brought out in the his-
tory. Some of these conditions date back to child-
hood, in which event they were considered to have
some gastrointestinal disturbance instead of an acute
appendicitis. I am glad to have had Dr. Macrae
refer to the necessity of differentiating between
chronic and acute appendicitis when we speak of
delay in making a diagnosis. I would be very sorry
to have the impression go out that I advocate delay
in any case of acute appendicitis — delay because of
waiting for the report of a laboratory test or any
other report. In every case of acute appendicitis I
believe that when the diagnosis is made, or even a
probable diagnosis is made, w'e should advise opera-
tion and do it just as soon as possible. In my paper
I have tried to emphasize one point which I believe
might aid us in avoiding poor results — that more fre-
quent exploratory operation should be done. As to
muscle-splitting incisions; I have not yet come to
the conclusion of Dr. Macrae that in every case an
exploratory incision should be made, but it is quite
likely that I may join him in that decision before a
great while. The greatest amount of dissatisfaction
that we should have in the summing up of these cases
is in regard to the fact that there is a large number
of cases in which a cure has not been obtained, but
only improvement. Those are the unsatisfactory re-
sults we should strive to account for.
VIXCENT’.S ANGINA AS SEEN IN CIVIL
PRACTICE*
J. E. Rock, M.D., Davenport
History
The object of this paper is to call attention to
and emphasize the importance of Vincent’s An-
gina in our work in civil practise, since there is
no doubt that the late war has increased its prev-
alence.
I do not propose to give an exhaustive review
of the disease, but simply to record some observa-
tions, personally made in a small way, and to pre-
sent some ideas given us by older observers who
have had a much longer field to work in.
The disease was first described by Professor
Vincent in 1898, and bears his name. At that time
it was considered of importance because of the
liability of its being mistaken for diphtheria. This
is still true and added to this factor is the in-
creased prevalence since the war, and the fact
that it may be overlooked or forgotten.
Etiology
The disease is bacterial in origin having for its
causative agent the fusiform bacillus and the ac-
companying spirillum, the accepted theory being
that the latter is an evolutionary step of the
former.
The cultural characteristics will not be ccm-
sidered in a paper of this length, excepting to
say that the organisms can be obtained by a direct
smear in the majority of cases.
Vincent’s Angina can be transmitted in ways
similar to other such diseases. Direct contact,
drinking cups, towels, improperly sterilized in-
struments in dental and medical offices, and nu-
merous other ways are responsible for its travel.
However, as in most such diseases our patients
tell us they have no memory of association with
persons who had any obvious disease; or of hav-
ing eaten away from home, and try as you may
you cannot find a satisfactory explanation for
their being afflicted. In our case records two of
our patients gave a history of having recently had
‘Presented at the Iowa and Illinois Central District Medical
.Association.
VoL. XII, No.81
Journal of Iowa State Medical Society
327
some dental work done, both of them having con-
sulted a dentist in regard to some third molar
trouble.
There are two {xjssible explanations here,
namely : Vincent’s organisms dormant under
these third molars, or poor aseptic technic on the
part of the dentist.
Exciting causes can he briefly cared for by;
oral sepsis, poor care of the teeth, dental caries,
excess tobacco, poor surroundings, poorly nour-
ished individuals, and unsanitary conditions.
Lesions — Their Locations and Appearances
The lesion is described as a heavy, dirty mem-
brane covering the tonsils. This is by no means
constant as the patches may appear any place on
the naso-pharyngeal or buccal mucosa, and ab-
sence of tonsils is no guarantee against an attack
of Vincent’s as one of our most severe cases was
in a nurse who had had a clean tonsillectomy.
The disease may manifest itself in dark yellow
spots on the tonsil, usually showing an excavated
or depressed center, covering an area that is so
necrotic that gentle pressure will often take a
cotton tipped applicator into the tissue for a con-
siderable distance.
In other cases, the first complaint is “sore
gums,” really a mild gingivitis, the teeth feeling
too large or too long, while in one case the first
complaint was of a tongue that was very sore and
swollen. Along the margins of the tongue, in-
feriorily, were severe, angry looking areas cov-
ered with the rather constant dirty yellow deposit
and marked by extreme tenderness when touched.
This rapidly extended until the tongue was three
times its normal size and very sore. In this case
there was but one spot on the right tonsil.
The gums soon show a thick, whitish-gray de-
posit which can be readily brushed off and under
which the tissue is very red and bleeds easily, and
is extremely painful.
The lips do not always escape, and lesions sim-
ilar to those already described may cover the
whole extent of both upper and lower lips. The
membrane may extend downward into the respii"
atoiA’ tract and is then exceedingly difficult to
handle.
We have been interested particularly in Vin-
cent’s Angina as a mouth and throat infection,
but in passing it may be well to mention that the
disease is not limited to this area as cases of
labial ulcers, balanitis, or the “fourth venereal
disease” and gastro-enteritis caused by Vincent’s
organisms are on record.
Symptoms
For a paper of this length and in a rather lim-
ited field we did not attempt to classify our pa-
tients into age, sex, nationality, etc., simply de-
siring to mention some of the outstanding fea-
tures, sufficing to say they were all young adults.
Each one of our cases had symptoms at the on-
set which would fit with an attack of acute fol-
licular tonsillitis, and here is where I think I have
an e.xcuse for this paper, as the clinical picture is
so clear for tonsillitis that some might be tempted
to consider it as such without looking further.
These symptoms of headache, backache, when
coupled with complaints about the teeth and
gums, and tender cervical glands should make
one look further. From the above symptoms
there is nothing very definite that would lead
anyone to lool^ for an unusual condition except
the two factors of gingi\itis and glandular swell-
ing with tenderness.
On examination the general condition strikes
one as being that of a per.son who is sicker than
the ordinary case of tonsillitis, the lips are fre-
quently covered with blisters, sordes, and there is
an odor from a real case of ^'incent’s that is char-
acteristic. It is the heavy, fetid smell of decayed
tissue.
On opening the mouth the teeth are always un-
clean because the gums are so sore and tender it
is impossible to brush them. There is also the
thin grayish deposit on the gums. It is not in-
frequent to find many carious teeth, or a mouth
filled with bridges and crowns.
The buccal membrane may be involved as is
also the palate, sometimes. The tonsils if pres-
ent practically always have the yellowish spot,
or larger membrane on them. This membrane,
especially on the tonsil, is very friable and easily
removed, after which there is not much bleeding
One case developed an enormous peritonsillar
abscess.
Smear and Culture
In every case of sore throat or sore moutli, a
smear and culture should be taken, because no
one should make a clinical diagnosis when he can
get laboratory help. The best place to make a
smear for Vincent’s is down behind the third
molar teeth. This will give a positive smear
where all other places fail.
Wassermann
Syphilis can and does of course, co-exist with
Vincent’s and the Wassermann test should be
made if the smears are negative, and in cases
which do not respond readily to treatment.
In a series of fifty-six cases reported by Reck-
328
Journal of Iowa State Medical Society
[August, 1922
ord and Baker in the Journal A. M. A. of Decem-
ber 11, 1920, page 1620, fifty-one cases gave neg-
ative Wassermann reactions, a proportion which
could be expected among almost any fifty-six in-
dividuals chosen as these were.
Surroundings, Habits, Etc.
In our cases there was no one living in real
poor surroundings and the only interesting facts
was a physician’s office nurse, and another w^as
an usher in a large theatre. They gave histories
of recent dental work.
Differential Diagnosis
In the typical cases the diagnosis is fairly easy
from the clinical appearance, but a good rule to
follow in all throat and mouth infections is to
make a direct smear and culture.
(a) Acute Follicular Tonsillitis, probably the
most common condition in the throat varies so
greatly in its clinical appearances that we may be
tempted into a hurried diagnosis and it is espec-
ially confusing since the onset of so many cases
of Vincent’s is accompanied by the systemic man-
ifestation that marks the onset of tonsillitis.
(b) Diphtheria is a membranous condition,
is usually more continuous than Vincent’s, is not
the yellow'ish color often seen in Vincent’s, is te-
nacious and bleeds when removed. It is not ac-
companied as a rule wdth the tender sub-maxillary
sw'elling. The laboratory report wdll clear any
doubt.
(c) Syphilis — Since syphilis can simulate any
condition it must always be borne in mind, in
cases which respond slowly or not at all to treat-
ment, a Wassermann reaction should be speedily
done.
(d) Aphthous Stomatitis may be confusing,
but it is usually characterized by the presence of
small slightly raised spots two to four millimeters
in diameter and surrounded by reddened areolae —
usually confined to the inner surface of the
cheeks and edges of the tongue.
(e) Ulcerative Stomatitis is important be-
cause of its tendency to break out as an epidemic
— the process begins at the margin of the gums,
the ulcers are covered with a grayish-white mem-
brane, and salivation and difficult mastication at-
tend the condition.
( f) Thrush, Gangrenous Stomatitis, and
Ptxalism may be merely mentioned in passing.
Treatment
From the jxiint of view of our patients this is
the most important part of any disease. And the
fact that there are so many advocated and highly
recommended treatments for Vincent’s Angina
is proof itself that no one is entirely satisfied.
However I am adding to the already long list,
since I have not heard it mentioned heretofore.
In Vincent’s as in other infections, the treat-
ment resolves itself into prophylactic and cura-
tive. In regard to prophylactic treatment, clean-
liness and care of the teeth is all any one can do,
and all jjhysicians and dentists know" aseptic
technic.
Curative — Salvarsan, intravenously and lo-
cally are highly recommended. Record and Baker
in Journal A. M. A. of December 11, 1920, rec-
ommended a solution of 0.6 grams of arsephen-
amin in 2 fluid drams of glycerine. Thorough
cleansing and drying of the parts and a direct ap-
plication of the arsenical mixture, rubbing it in
well. They also recommend a 2 per cent solution
of chromic acid applied locally.
Silver in various percentages is used, concen-
trated iodine solutions, methylene blue, and va-
rious other remedies.
I desire to add carbolic acid as the agent which
has given us best results. A 1 per cent solution
used in a dental or chip syringe or even an atom-
izer. This is sprayed directly on the part af-
fected using force on the syringe. In a day or
so or even the next day it is increased to a 2 per
cent solution and in one case w"e started with a 2
per cent solution. It is quite pleasing to note the
w'ay an angry sore mouth will clear with this
treatment, how" pain will leave and the condition
improve. The longest time it has been necessary
to treat cases this way has been six days and this
was an extremely violent case. The shortest was
three days.
Potassium chlorate 1 to 5 per cent can be used
as a mouth wash together with the spraying of
phenol, but it usually causes too much pain. Sil-
ver nitrate 6 per cent can be used, but is not of
much avail.
Forcing fluids, catharsis, and general treatment
are the same as in any infection. After recoverv
thorough dental examination and correction is
absolutely necessary, and I think I should strongly
recommend the extraction of the offending third
molar teeth.
Conclusions
1. The prevalence of Vincent’s Angina does
not seem to be thoroughly recognized.
2. Distinct relationship between the disease
and dental caries.
3. Region of third molars is habitat of choice
of the organisms.
4. .Spirochaetal in bacteriology.
5. Necessity of smear and culture from all
mouth and throat cases.
6. Good results with phenol sprays.
VoL. XII, No. 8]
Journal of Iowa State Medical Society
329
THE HOSPITAL AND LABOIO\TORY AS
AN AID IN DIAGNOSIS AND TREAT-
MENT OF DIABETICS*
E. L. Rohlf, M.D., Waterloo
I have not chosen this subject for the purpose
of demonstrating any superior knowledge, for 1
haven’t it, but rather to provoke discussion and
profit thereby, and to illustrate how patient and
physician may both be more comfortable, by re-
ceiving accurate data upon which to base intelli-
gent and helpful treatment.
It is an admitted fact that rarely if ever does
an individual showing both urine and blood sugar
ever develop a normal intolerance for carbohy-
drates. Therefore every patient who comes under
our observation and care, showing urine or blood
sugar, or both, immediately becomes an object of
constant study for the physician. W'^ith three ob-
jects in view ; 1st, the finding by quantitative tests,
from twenty-four hour specimens of urine, how
much sugar is excreted in twenty-four hours —
also the glycocemic content of the blood under his
usual dietary. Second, finding the patient’s carbo-
hydrate tolerance, by allowing known quantities
of food, having a known carbohydrate value, and
even using the starvation diet for such period of
time as will make the patient sugar free, then
gradually adding known quantities of carbohy-
drates to his diet until sugar reappears in the
usual reaction tests ; then feeding a little below
this known quantity of sugar forming foods.
' Important during this laboratory and dietory
studv period, that we should constantly keep a
record of the diacetic acid content in the urine as
an indicator of the functional reaction of the pa-
tient in response to the dietary treatment, or dis-
aster might occur in the form of acidosis. Third,
educating the patient during this laboratory pe-
riod, as to the effect of diet, the value of proper
diet, and how to combine different foods to pro-
cure the proper estimated amounts of sugar form-
ing foods, proteins and fats, to make up the re-
quired calories necessary to produce sufficient
energy and heat, and maintain the proper weight
of the patient. This educational process must
continue practically during the life of the patient,
unless unusually intelligent and well able to con-
trol his cravings for unallowable food, the better
informed a patient becomes, the better he will be
able to care for himself. As diet is the only pro-
tection a diabetic has, the value of educating him
becomes emphatically important to you all. It
adds to his comfort and longevity, and protects
*Read before the Austin Flint-Cedar Valley meeting, July 19,
3921, Clear Lake, Iowa.
against dangerous complications which lurk in
the wake of the disease, and frecjuently termin-
ates the life of the individual.
It is unnecessary perhaps, but 1 want to em-
I)hasize the fact that even- diabetic is emphatic-
ally a hospital case, in a hospital with proj)er lab-
oratory facilities and in charge of an accom-
plished technician until such time as a proper
basis for diet has been worked out.
Few, if any, offices are equipped for carrying
on this important work — I want to admit at this
time that I am not a laboratory technician, and
depend entirely upon the data procured by our
hospital laboratory for a basis upon which to
build my treatment for my patient. And I want
to say this, that the careful study of each case is
a post graduate course on this particular type of
disease, until one has become thoroughly familiar
with all the details.
To emphasize the necessity for hospitalization
of these cases, I want to give you the statistical
result in percentage of deaths in the treatment of
diabetics in the Massachusetts General Hospital
during the period of from 1913 to 1918; 1913, 30
per cent; 1918, 2 per cent. This one hospital
alone fumishes sufficient evidence for my plea
for hospital treatment for diabetics. All hos-
pitals may not arrive at so low a mortality, but
certain it is that more efficient service can be
rendered, and innumerable lives prolonged, and
be made much more comfortable while they do
live.
We must admit that the general care of the
diabetic is far from perfect, but the efficient and
diligent study of such men as Allen and Joslin
and others will continue to produce valuable in-
formation which we may use for our unfortunate
patients.
Some authors make a distinction betw'een urin-
ary diabetes and diabetes mellitus, the differentia-
tion being in the quantity of blood sugar present
when sugar is also present in the urine — when
blood sugar remains in normal quantity in the
blood, it is not a true diabetes mellitus, even
though sugar be present in the urine. Blood
sugar also furnishes a basis for prognosis in that
the higher the percentage the more serious, and
vice versa. The laboratory furnishes our only
means for obtaining this knowledge. Also, we
must remember that the blood sugar content may
be abnormally high before it can even be demon-
strated in the urine. An important factor I had
nearly neglected to mention in the education of a
diabetic patient is to teach him any of the usual
tests for sugar, that he may be able to constantly
control his own condition.
330
Journal of Iowa State Medical Society
[August, 1922
Summary
1. Hospitalization of patient important.
2. Quantitative laboratory investigation of
urine and blood.
3. Finding the carbohydrate tolerance and
establishing the proper dietary to meet this tol-
erance and remain sugar free.
4. Educating the patient as to food value, per-
centage combinations, and the importance of
dieting.
5. Teach him the ordinaiy tests for sugar and
furnish him the necessaiy re-agents.
6. Teach him the ordinary" rule of hygiene
which he must observe.
7. Impress him with the fact that he is prac-
tically his own medical observer, dietetian and
technician. He being the greatest gainer — in that
he will avoid complications, increase his comfort
and add years to his life.
MENTAL MEASUREMENT IN RELATION
TO MEDICINE
Reuel H. Sylvester, Ph.D., Psychologist, Des
Moines Health Center
The greater part of this paper will necessarily
have to be devoted to description and interpre-
tation of mental measurement. This must in turn
be prefaced by a brief discussion of psycholog)'
which is the general science of which mental
measurement is a concrete application.
The word “Psychology” is shamefully over-
worked and misused. For several years it has
been the prey of charlatans, fourflushers, bluf-
fers and ignoramuses until at sight or sound of it
we are more likely to be disgusted than interested.
There seems to be no end of magazine articles,
books, lectures, and advertisements on the psy-
chology' of religion, psychology of advertising,
psychology of adolescence, psychology,' of dreams,
psychology of the strike, psychology of salesman-
ship, psychology of health, psychology of child-
hood, and the hundreds of other similar vague
titles that force themselves ujxdu us. The climax
certainly has been reached, however, in the now
prevalent question, “What is the psychology of
this situation?” or, “The psychology of this act?”
or “The psychology of that man?” these questions
being offered merely for the sake of conversation,
just as we will in talk about the weather.
But there is a genuine psychology, a real
science that is of such importance and such gen-
uineness that I am proud to have the privilege of
presenting an aspect of it before the medical so-
ciety. I only ask that my hearers clear their
minds of all rubbish that masquerades under the
name of psycholog>', and that they understand the
reader to be discussing a science that is as limited
in its field, as genuine in its methods and as re-
liable in its results, as are the sciences of chem-
istry, physics and biology'.
The history of psychology dates back only
about a half century. It is in that comparatively
short time that we have discovered that certain
mental functions, and perhaps the whole mind it-
self can actually be measured. We know little,
perhaps nothing, as to what mind is, but that need
not deter our measuring it and handling it scien4
tifically any more than ignorance of what elec-
tricity actually is, need make it unmeasurable or
unusable. The modern psychologist does not
care whether mind is matter or distinct from mat-
ter or a product of matter. He leaves those prob-
lems to the philosopher.
Measurement of mind began with the measure-
ment of reaction time. We still say a thing hap-
pens quickly as thought, meaning thereby that it
happens instantly. As a matter of fact we now
know that there are several things that happen
much more quickly than thought ; that it takes a
measurable length of time for a brain cell to act
and for a thought or nerve impulse to pass from
one part of the body to another. It was from
this measurement of reaction time that other
mental measurements sprang. Now vision, audi-
tion, and other senses are measured in well es-
tablished methods in practically every psycholog-
ical laboratory. It has also been found that
memory can be analyzed and measured. Other
mental functions and processes are now meas-
ured, in fact during the past fifteen years psy-
chologists have plunged boldly ahead on the as-
sumption that any mental process can be measured
and that the only problem is to isolate and to
devise measuring methods.
Such measurements are all in the direction of
analysis- of mind and measurement of isolated
processes. General psycholog)' has not yet bal-
anced and evaluated the various processes in any-
thing like a satisfactory way, so while able to
measure many of them we are not always able to
interpret the results and to make them of diag-
nostic value. For instance, we do not know how
much weight we should give the results of mem-
or)' tests as compared with results of sensory
tests, neither are we certain that our tests of
memory are complete or properly balanced for
evaluating that one special function. Psychol-
ogists have been partly unsuccessful and partly
negligent in the study of emotions. Although the
emotional aspects of consciousness are of the
greatest importance in studying mental diseases.
VoL. XII, No. 8]
Journal of Iowa State Medical Society
331
the psychological laboi'atory has developed very
few tests and measurements that are helpful.
Nearly all of the present devices and tools are
for a study of the knowing, with little considera-
tion of the feeling. For that reason laboratory
psycholog)' has been somewhat of a disappoint-
ment to the psychiatrist who has developed his
methods, largely from the point of view of symp-
toms of mental disease, which are largely notice-
able as feeling aspects. Since psychology has not
yet completely analyzed mental processes and
weighted and correlated them, mental tests and
measurements are lame when it comes to evaluat-
ing the total of results in terms of a general es-
timate of intelligence.
Because of the incompleteness of the analytical
tests that we have just been discussing and be-
cause of the reliability of statistical methods,
psychologists have rnost recently given consider-
able attention to the developments of measuring
scales of general intelligence. In these scales
there is not a visible analysis into the various
mental functions. Questions and tests of mem-
ory, reasoning, imagination and other processes
are simply thrown together and measured as a
whole.
The most ^■aluable of all such scales is the one
devised by Alfred Binet, a French psychologist.
I shall not at this time go into details of the his-
tory of these tests, interesting though it would he
to trace them from their first crude form through
the various revisions and to their present form.
For use with individuals who do not see, hear
and speak perfectly, or who for some other rea-
son cannot be tested fairly by the Binet scale,
performance tests have been devised. They in-
volve the use of puzzles, form boards and other
devices of various types. These performance
tests are valuable but none of them are nearly
so reliable as the Stanford-Binet scale.
Lately there have been developed several group
tests for testing several individuals at once. They
demand an entire paper, so I only mention them
here.
^ much for psychological tests themselves.
Tests are not the main part of a mental measure-
ment. They are only devices, accessories, and
their results need interpretation in the light of
case history, general mental behavior and a full
knowledge of the individual. The examining
psychologist must bring to focus on the case all
of his knowledge and experience with mental
phenomena.
It would be absurd for a physician to attempt
to diagnose on the basis of laboratory and clinical
tests alone. He has many valuable tests at his
command but like psychological tests they are
for the most part merely devices. This is es-
pecially true of functional tests. It is hardly pos-
sible to measure accurately the functioning of the
glands and organs but there are many functional
tests that help greatly as diagnostic accessories.
Psychological tests are functional and must al-
ways be so considered. One cannot measure so
complex and subtle a function as mind in any-
thing like the same way that he can measure sucli
static quantities as height and weight.
Therefore psychological examinations and
mental measurement must take into consideration
family history, developmental history, home and
environment report, school history, and general
physical examination reports. This rather wide
variety of infoimation is necessary, and besides
the psychological test results, which were dis-
cussed earlier in the paper, a number of general
questions must be answered by the individual and
his performance observed in the solution of puz-
zles and complex problems and unusual situations
— none of which are included under standardized
tests.
All these are evaluated and interpreted in the
light of the examiners knowledge of psychology
and his experience as an examining psychologist.
Final results are usually stated in terms of very
superior, superior, average, inferior, or very in-
ferior intelligence with supplementary statements
as to what mental weaknesses and strengths have
been revealed.
The foregoing explanation of mental measure-
ment and the discussion of methods are intended
to clear up the situation so that we may in a final
paragraph discuss directly the topic of the paper.
Mental Measurement in Relation to Medicine.
This relation is essentially that of other special
laboratory relations. The results of a mental
measurement should contribute to a physician’s
diagnosis and handling of a case in much the
same way that x-ray findings, Wassermann test
results and other laboratory results contribute.
Usually however, the mental measurement does not
reveal a disease or an acute ailment of the mind.
It gives the physician exact information as to the
grade of intelligence and the type of mind with
which he is dealing. This is fundamental to his
understanding of causes, present condition and
treatment, and involves considerations that are all
too frequently overlooked.
This is the reader’s conception of mental mea-
surement’s relation to medicine. His experience
and observation convince him that many patients
may be better understood and their treatment
more effectively prescribed if among the special
tests and examinations that are made mental
measurement is included.
332
Journal of Iowa State Medical Society
[August, 1922
PRESIDENT’S ADDRESS*
Charles Ryan, M.D., F.A.C.S., Des Moines
Members of the ^Missouri Valley Medical As-
sociation : I wish to thank you individually and
collectively for the honor which you conferred
upon me in Des Moines one year ago, and to as-
sure you of my earnest appreciation of that honor
and the gratification I feel in being given the op-
portunity to serve you. It has been a real pleas-
ure, and one which will live long in my memory.
I wish to thank you also for the cooperative spirit
shown by the officers and members in general,
and to express my highest appreciation to Doctor
Lord, the members of his committee and the
members of the Douglas County Society who
have made this splendid meeting possible. We
are glad to be with you here in Omaha today,
and we will be pleased to come again.
At this time I purpose a brief resume only of
some of the more important things that have to do
with a subject in which we have been greatly in-
terested during the past few years.
The practice of medicine carries with it certain
duties and obligations to hvimanity in the ever
present problems which present themselves in our
struggle with abnormalities and diseased condi-
tions to which the human being is heir. These nu-
merous duties and obligations when analyzed can
be expressed in one word — -“Service.” The inter-
relationship of all civilized people, irrespective of
class or vocation, demands in their associations
many actions, deeds, words and thoughts which
can be classified either as a private or public ser-
vice. We, as practitioners, in the art and science
of healing have only our time, attention, care
and application of our knowledge with which to
serve the community.
The Golden Rule does and should express the
moral standard of the medical profession today
and tomorrow unchanged. The scientific stand-
ard and the art of medicine is ever changing for
the betterment of all concerned. The medical
profession, together with its allied institutions ;
the hospital, the dispensary, the free clinic, the
public health service, the nursing associations, the
research workers, the experimental laboratories,
etc., are untiring in their efforts to reach the
height of efficiency, are eager and ready to adopt
any and all accredited measures, and methods
which better equip them to attain the results de-
sired in the prevention, alleviation and cure of
disease. Again I will state that the sum total of
all the thought, time, energy-, efforts and applica-
’Medical Societv of Missouri Valley, Omaha, Nebraska, September
6, 1920.
tion of all these amalgamated institutions of med-
icine, either in time of peace or war, can be given
expression in the one word “Service.” We are
the servants of the public, engaged in the practice
of medicine and surgery, and as such we enjoy
one of the greatest of God given privileges; if
then, service be our lot, let the service given be
of the most approved and highest type, giving al-
ways the best that is in us. To do this, it is a
part of our obligation to the commonwealth to
accept and discharge our full duties in citizenship,
in social life, in political life and in business life,
as well as in professional life; to hold ourselves
ready and willing at any and all times, not only to
endorse but to do all in our p>ower for the success
of any project which has for its purpose the bet-
terment of humanity. In this connection I wish
to remind you today of a movement in our own
profession, which if you will give to it due con-
sideration and earnest thought, will I am sure,
enlist not only your endorsement but also your
enthusiastic support. I refer to the necessity and
object of standardization of the medical practi-
tioner, the medical school, the hospital and all kin-
dred institutions. Over a decade past, the Amer-
ican Medical Association saw the necessity of re-
form and through its efforts countless poorly
equipped and sub-standard medical schools ceased
to exist, thereby putting an end to numerous di-
ploma mills. All agree that this was a move in
the right direction. We are cognizant of the fact
however that many of our most efficient and cap-
able men in the medical profession today spent
their student days, and graduated from schools
which by reason of standardization have ceased
to exist. These men, however, possessed the in-
born initiative and ability which by close applica-
tion and hard work brought them up to the high
standard of efficiency required at the present
time ; and it is many of these same men who are
now the most ardent supporters of this great
movement for standardization. With the raisinsr
of the standards, entrance requirements, etc. of
medical schools fewer men are being graduated
in medicine today, but these men after a hos'pital
service are, as a body, much better educated,
better equipped, and better trained in the funda-
mentals and principles of medicine than those
who have preceded them. As a result of this
standardization, the ranks of the healers and
charlatans have been greatly augmented by those
who shun the rigors of real preparation. The
answer to this situation is that the contrast will
strengthen the medical profession and that the
graduate of the medical school will stand the test
of time, while the healer and charlatan will fail.
VoL. XII, No. 8]
Journal of Iowa State Medical Society
333
Hospital standardization through the efforts
of the American College of Surgeons, the Amer-
ican Hospital -Vssociation, the Catholic Hospital
Association, the American Medical Association
and the medical schools, etc., has become a reality.
The standard of requirements has been adopted
in numerous hospitals in many of the states and
is converting more institutions daily to the value
and necessity of such standards as are required.
The fundamental elements of this work as given
by Franklin Martin are
First — The patient.
Second— The doctor who treats the patient.
Third — The equipment and intelligent adminis-
tration.
Fourth — Adequate nursing facilities.
Fifth — Diagnostic laboratories in charge of a
practical laboratory man.
Add to these fundamentals
(aj The service of resident physicians in
number according to the capacity of the hospital.
(b) The keeping of complete case records.
(c) Regular monthly meetings of attending
staff to discuss and cooperate with the superin-
tendents, and trustees in everything which has
to do with the service given in the institution. I
am sure you will agree that these requirements
are for the best interests of the patient and com-
munity in general.
These rules and regulations are not alone for
large hospitals with a large attending staff, but as
Crile has stated, “The standardization that is in
our minds here today is not the standardization of
the great institution. High scientific service in a
hospital does not necessitate a large number of
beds ; it means merely that if a hospital has but
one f)atient, and one member of the staff, if the
member of staff gives that patient a fair show and
square deal in the way of intelligent treatment,
the hospital will meet any standard which we may
properly set up. The patient must have the ad-
vantage of good nursing.” In the hospital prob-
lem of today, Hornsby says: “No hospital can be
better than its medical staff, and no medical staff
has the right to expect evaluation of its abilities
higher than the prima-facie evidence at hand in
the equipment and in the methods employed in
the workshop in which the work is done. We all
know institutions elaborate in architecture, great
in size, and rich in endowment, that are mere
boarding houses for the sick ; and we know that
in many of these institutions the medical staff is
mediocre, without ambition, energ}' or enter-
prise, we all likewise know small isolated insti-
tutions far out in the country, small in size, poor
in worldly goods, and almost without equipment,
or funds with which equipment may be bought,
whose service to the sick is of a high scientific or-
der and in which the sick man, woman or child
may have at his need the best that modern medi-
cine offers.”
In our daily routine hospital work, we must
realize and accept our responsibilities in teaching
and training interns and nurses, as well as as-
sistants, for these young people must take the
reins of active duty and render the service when
we shall have passed along, and we should grasp
every opportunity to assist them in obtaining the
knowledge which is to serve them well in their
professional career. In keeping with the stand-
ardization of the institutions referred to, it is the
opportune time for the organization of well
equipped and well appointed post graduate schools
of medicine and surgery, where the purpose is to
furnish a more thorough course of study to those
wishing to avail themselves of it. It is a deplor-
able fact that in the past the majority of post-
graduate schools have been markedly inefficient
in their methods ; have been organized with too
much the purpose of commercialism, and they
should be brought up to an efficient standard,
that they may justly deserve the patronage they
enjoy. Through the correct avenue is coming
hand in hand with standardization of medical
schools, hospitals, etc., the standardization of
training schools for nurses, requiring better pre-
liminary education, raising entrance requirements,
etc., for the young women who elect nursing as
a profession.
We must personally strive to interest and en-
thuse the members of directory boards, trustees,
etc., of our local institutions, as well as the public
in general in this great movement, which when
instituted gives the patient (be he rich or poor)
first consideration in our thoughts and in our
efforts to return him to his usual activities and
vocation in life in the shortest time possible with
the minimum amount of pain and discomfort, as
well as expense during his hospital experience.
Standardization has for its object the best pos-
sible care for the sick and maimed from every
viewpoint, and as such should stimulate us into
putting forth our strongest efforts to see its
adoption universally ; as charity begins at home,
so also does standardization. We must first of
all standardize ourselves individually and measure
up to that standard, not only to the standard
which we set for ourselves, but better still, we
should measure up to the standard which we set
for the other fellow.
334
Journal of Iowa State Medical Society
[August, 1922
JEije BJournal of tiie
Sotoa ^tate illebtcal ^octetp
D. S. Fairchild, Editor Clinton, Iowa
Publication Committee
D. S. Fairchild Clinton, Iowa
W. L. Bierring „Des Moines, Iowa
C. P. Howard Iowa City, Iowa
Trustees
J. W. CoKENOWER Des Moines, Iowa
T. E. Powers Clarinda, Iowa
W. B. Small Waterloo, Iowa
SUBSCRIPTION $2.75 PER YEAR
Books for review and society notes, to Dr. D. S.
Fairchild, Clinton. All applications and contracts
for advertising to Dr. T. B. Throckmorton, Des
Moines.
Office of Publication, Des Moines, Iowa
Vol. XII August 15, 1922 No. 8
THE ECONOMIC POSITION OF HERNIA
For several years the relation of hernia to acci-
dent and injury has been well established in the
minds of surgeons of experience, and yet, there
were points of contact not quite determined which
could be utilized by those having to deal with the
question in a practical way. The term “trau-
matic hernia” had been misleading. One sur-
geon would say that he had never seen a case.
Another would say that traumatic hernia was
very rare, still another would say that a hernia
with a sac was not a traumatic hernia. All these
statements were quite true but did not meet the
serious problem of the true relation of hernia to
accident and injury. It could not be denied that
a hernia with a formed sac, did sometimes appear
as the result of a severe injury or strain; that a
hernial tumor did sometimes appear under such
circumstances, where no tumor existed before,
producing a period of disability and entitling the
injured person to compensation, a fact admitted
by compensation boards, corporations, and others.
There was also a larger class of hernias which
existed before the accident, and had no relation to
injury, and which slipped back and forth freely
without pain. These cases were not entitled to
compensation. It had become important, there-
fore, that some well defined rule should be
adopted that would draw a distinct line between
compensable cases and non-compensable cases,
and by which a fair and reasonable compensation
might be mea.'iured. That some authoritative state-
ment should be made, the IMedical and Surgical
Branch of the American Railway Association ap-
pointed a committee to report on hernia, with Dr.
Wm. B. Coley of New York as chairman. After
two years’ investigation and consultation, the
committee made its report at St. Louis, iVIay 22,
23, 1922. It will be seen that not only is the ques-
tion of traumatic hernia considered, but the vastly
more important subject of hernias associated with
accident and injury, and entitled to compensation
are taken up in a fair and judicious manner,
which should be of immense value to workmen’s
compensation boards, corporations and claimants.
We believe, furthermore, that this report will be
of material aid to the medical profession in
determining the question of damages in hernia
cases. The question of hernias is of immense im-
portance to industries which are frequently called
upon to pay large damages for hernias which
existed before the alleged injur}' occurred, in-
deed, before employment was secured. The
hernia problem had been considered in European
countries some years ago, but this report is a
purely American product and should escape
prejudice.
NEUROPSYCHIATRIC PROBLEMS WITH
DISABLED VETERANS
As every one knows there has grown out of the
late war thousands of disabling conditions acting
to impair in greater or lesser degree the economic
efficiency and independence of ex-service men.
To minister to their needs there has been created
by the Federal Government the United States
Veterans’ Bureau with its fourteen district of-
fices, each embracing certain states of the Llnion.
The functions of the United States Veterans’
Bureau are mainly three ; first, to provide ade-
quate medical care and treatment for the disabled
ex-service man; second, to afford them where
eligible and feasible vocational training leading
to their industrial rehabitation, and, third, to ade-
quately compensate in money those for whom
treatment has not resulted in recovery and where
the disability is such that vocational training is
not feasible. As will be seen the United States
Veterans’ Bureau has been given the responsibil-
ity towards the disabled ex-service man which
was formerly divided between the United States
Public Health Service, the Bureau of War Risk
Insurance and the Federal Board for V ocational
Education. To discharge this enormous respon-
sibility a large organization has to be built up,
each district being practically in charge of its own
problems working in decentralized manner from
VoL. XII, No. 81
Journal of Iowa State Medical Society
335
The central office in Washington. This organiza-
tion includes clinics, and hospitals with their so-
cial service allies, special schools and supervision
of universities and colleges wherein training is
carried on. Our state comes within the territory
known as the ninth district, including Missouri,
Kansas, Iowa and Nebraska. The district head-
quarters, with Mr. M. E. Head as district mana-
ger, are located at 6801 Delmar Boulevard, St.
Louis. There are fourteen sub-district offices lo-
cated at St. Louis, Kansas City, Springfield,
Poplar Bluff, and Chillicothe, Missouri; Wichita,
.Salina and Topeka, Kansas; Des Moines, Cedar
Rapids, Waterloo and Fort Dodge, Iowa. At St.
Louis and Kansas City, Missouri, Colfax and
Knoxville, Iowa, are large hospitals ; and at St.
Louis, Kansas City, Omaha and Des Moines large
out patient clinics. Any one of these branches
will gladly suppl)' information concerning the
Bureau’s purposes and work, as will the district
manager to any interested persons.
As will be seen by the foregoing brief setting
forth of the Bureau machinery the work deals
with disabilities resulting from injury or disease
and is therefore fundamentally medical. It has
been noted with some alarm that a large portion,
fully one-third, of all disabilities are of nervous
or mental type — neuropsychiatric. The alarm and
concern arises from the difficulty inherent in the
handling of men with disorders of the nervou*:
functions. To accomplish things it is primaril}'
essential that there be a personnel of adequately
trained neuropsychiatrists and it has been brought
to the editor’s attention that the Bureau experi-
ences considerable difficulty in obtaining the ser-
vices of such men. From time to time there are
opportunities open in the neuropsychiatric sec-
tion of the Bureau for men with the proper train-
ing to work as special examiners or on a part or
full time basis. The work itself is of vast inter-
est, opening up as it does a practically untried
field in the application of neuropsychiatry to the
solution of industrial, vocational and economic,
problems. Neuropsychiatrists are particularly de-
sired at this time and any with the training are
requested if interested to communicate directly
with the district manager, Mr. M. F. Head, 6801
Delmar Boulevard, St. Louis, for further inform-
ation.
Graduates of Drake University School of Medi-
cine, College of Physicians, Keokuk Medical College,
all of whom are now alumni of the University of
Iowa College of Medicine will hold class reunions
at the 1922 commencement of the university, when
many of them will make their first intimate acquaint-
ance with their new alma mater.
PROVIDING FOR AN INCREASE IN NUMBER
OF RURAL DOCTORS
We are informed by Virginia Medical Monthly
that a bill has been introduced in the legislature
of Virginia authorizing the College of Medicine
and \’irginia University to offer two scholarships
from each congressional district which shall en-
title the holder to tuition in the department of
medicine of each institution and to $250, an-
nually.
The bill provides that the scholarships shall be
assigned, after competitive examination, to the
two persons in each congressional district mak-
ing the highest grades. The bills give each insti-
tution twenty scholarships.
It is further provided that each of the students
after graduation shall practice medicine for a pe-
riod of not less than five years in the rural sec-
tion of the congressional district from which he
or she was appointed, and if the person violates
the agreement to practice medicine in the rural
district after graduation, authority be vested in
the University of Virginia and the Medical Col-
lege of Virginia to collect by law such amount as
the student has received from the scholarship.
Each bill appropriates $5,000 for each of the
years ending February 28, 1923, and 1924, to
carry out the provisions in each measure.
DIVISION OF FEES
It is sincerely believed that the secret division
of fees among the better class of physicians and
surgeons in the Middle West has largely disapp-
peared. But that this practice still exists among
a considerable number of commercially inclined
there is abundant reason to believe. To guard
against a revival of this illegal practice the execu-
tive committee of the Missouri State Medical So-
ciety adopted the following resolutions ;
Whereas, It is reported that some members of our
Association are practicing the secret division of fees
in order to obtain patients, which practice is a vio-
lation of the by-laws of our Association and of the
Principles of Medical Ethics, therefore be it
Resolved, That the Councilor of each district is
hereby requested to warn the members of each
county society in his district against such practice
and that the component societies be notified that the
executive committee warns them against permitting
this practice among their members; be it further
Resolved, That the executive committee bring this
matter to the attention of the Council at the annua!
meeting in May, 1922, for further action against such
societies that fail to discipline their members for
such violation of the by-laws and of the Principles
of Medical Ethics.
336
Journal of Jowa State Medical Society
[August, 1922
FOWLER’S SOLUTION
The British Medical Journal for January 21,
1922, publishes a historical account of the intro-
duction of. Fowler’s Solution in the treatment of
ague.
Towards the end of the eighteenth century a
secret patent specific against ague was popular
in Berlin, and these tasteless ague and fever drops
came into vogue in England and were occasionally
used from 1780 to 1783 at the General Infirmary
of the county Stafford, where Fowler was phy-
sician and a Mr. Hughes the apothecary.
In October, 1783, Hughes told Fowler that he
had found that the active constituent of this se-
cret remedy was arsenic, and that he had made up
a solution of arsenic to take its place; this sub-
stitute was tested and compared as regards its
effects on patients. In 1786 Fowler published a
pamphlet of 128 pages on its effects.
REPORT OF THE SPECIAL COMMITTEE ON
TRAUMATIC AND INDUSTRIAL
HERNIA
American Railway Association, Medical and Surgical
Section
Dr. W. B. Coley (Chairman), Chief Surgeon, New
York Central Railroad.
Dr. Southgate Leigh, Chief Surgeon, Virginian
Railway.
Dr. J. B. Walker, Surgeon, Pennsylvania Railroad.
Dr. C. W. Hopkins, Chief Surgeon, Chicago &
Northwestern Railway.
Dr. J. A. Hutchison, Chief Medical Officer, Grand
Trunk Railway System.
New York, April 10, 1922.
To the Medical and Surgical Section:
The Special Committee on Traumatic and Indus-
trial Hernia, which was appointed as a result of ac-
tion taken at the last meeting of the Section, has
held meetings on October 11 and October 26, 1921.
The Committee has made a very careful study of
this most important subject and as a result has pre-
pared the attached treatise which it is believed will
be of real value in handling cases of this nature.
Action Recommended
That the report be approved for inclusion in the
Proceedings.
Respectfully submitted.
Special Committee on Traumatic and
Industrial Hernia.
Exhibit A — Traumatic and Industrial Hernia
The great increase in Social Legislation in recent
years has made the subject of Traumatic Hernia one
of vital importance to every industrial organization.
The first Workmen’s Compensation Act was
passed in Germany in 1884. Similar laws were soon
adopted in Austria and later in Denmark, Norway
and England.
In 1916 thirty-three states and territories in the
United States had enacted some form of Workmen’s
Compensation Act and since that time other states
have been rapidly following the lead. Therefore,
traumatic or industrial hernia, at first largely, a
question of theoretical interest, has become one of
great practical importance. In spite of this, there
has been no definite attempt made to standardize our
knowledge of traumatic hernia, particularly as re-
gards its etiology.
In the recent past the question of compensation
has too often rested upon the power of the plaintiff’s
attorney to stir the emotions of the jury rather than
upon a carefully weighed judgment based upon a
knowledge of the facts relating to the origin of
traumatic hernia.
The time has now come when these cases are be-
ing gradually taken out of the hands of emotional
juries — the members of which, no matter how fair-
minded, are naturally lacking in the technical knowl-
edge of the etiology and pathology of hernia — and
being passed upon by experienced physicians. There-
fore, it is of greatest importance that all of the facts
bearing upon the etiology of hernia should be col-
lected and classified and made readily available.
The term, “traumatic hernia’’ has been used in a
very general way to include first, the small group of
cases in which the hernia is due to direct violence;
second, an occupational hernia, or perhaps, as better
classified by the French, “hernia of effort,” which
includes all of those cases in which the hernia ap-
pears during heavy lifting, slipping, falling, coughing,
sneezing, or any cause whatever which increases the
intra-abdominal pressure; and third, “hernia of weak-
ness” which is due to abnormal or defective develop-
ment of the abdominal wall at the various hernial
sites.
The first group of cases is so e.xceedingly rare that
it may be disposed of in a few words. In true trau-
matic hernia due to direct violence the tissues must
have been punctured by some more or less sharp ob
ject which has forced its way at least through the
muscles and fascia, if not quite to the peritoneum.
Coley has never seen a case of true traumatic hernia.
He has known of one treated by one of his col-
leagues; the muscles about the inguinal canal were
torn by the horns of a bull and a hernia developed
shortly after. So this group of cases can be prac-
tically ruled out of consideration. The third group,
hernia of weakness, due to congenital weakness of
the abdominal muscles or weakness through disease,
causing atrophy of the muscles, is also very rare, as
weakness alone without the presence of a preformed
congenital sac, rarely results in a hernia no matter
how great the intra-abdominal pressure. These are
practically all of the direct type.
The very large group of cases which is ordinarily
designated as traumatic hernia and which should be
VoL. XII, No. 8J
JouKN.^L OF Iowa State Medical Society
337
more properly called occupational hernia, or, better
still, hernia of effort, furnishes the basis of nearly all
of the medico-legal or compensation cases of hernia.
The word “rupture,” the old English name for the
disease hernia, is responsible for the traumatic
theory of the origin of hernia so widely held by the
laity as well as by many medical men who have
given but little study to the subject. This theory
gained a foothold before operation for the radical
cure came into general use and before the etiology
of hernia was generally understood. With the rapidly
increasing knowledge of the subject derived from a
very large number of operations that have been per-
formed in the last quarter of a century, our ideas
of the causes of hernia have gradually changed. At
present it is almost universally recognized that the
all-important cause of hernia of all varieties is the
presence of a pre-formed sac of peritoneum known
as the processus vaginalis. This view was held by
two noted surgeons of the eighteenth century, Pel-
latin and Cloquet, but only in recent years did Rus-
sell of Australia, by his patient investigations, force us
to conclude that practically all herniae are of con-
genital origin, due to this open pouch of peritoneum
which has existed since birth. Unfortunately, courts
and juries and compensation laws here and abroad
have not kept pace with the developments of surgery
and it is still not unusual to see large damages
awarded in cases of so-called traumatic hernia. Rus-
sell maintains that an acquired hernia does not exist
and recognized authorities on hernia have come to
agree with Russell’s conclusions.
Prior to the adoption of the Workmen’s Compen-
sation Acts there were a considerable number of
medico-legal decisions in cases of so-called trau-
matic hernia both in Europe and in America. Many
of our compensation boards have simply followed
along the lines of decisions handed down by Europ-
ean courts. Sheen (Practitioner, London, 1909), who
has made a careful study of the subject of traumatic
hernia in England, states that “the arbiter in these
claims, in the mass of ill-understood technicalities,
following the lines of least resistance, has given judg-
ment in favor of the workingman — the post hoc ergo
proper hoc view being naturally considered the
easiest one.”
In Switzerland a person suffering from a hernia
and desiring compensation is entitled to indemnity
only on the following conditions: (1) It must appear
suddenly; (2) it must be accompanied by pain; (3)
it must be of recent origin; (4) there must be proof
that the hernia did not exist prior to the accident.
In Germany, in order to establish a claim, the suf-
ferer from hernia must have had an examination
within forty-eight hours of the accident; the hernia
must have appeared suddenly, must have been ac-
companied by pain and must have immediately fol-
lowed some accident. Proof must be furnished that
there was no hernia prior to the accident.
While there are no published records showing the
results of the New York State Compensation Board,
Sellenings, through the courtesy of a medical of-
ficer of the commission, has obtained certain im-
portant data. The commission thus far has con-
sidered traumatic hernia as extremely rare. The
opinion was ventured that it occurred in possibly one
of ten thousand cases. Commenting upon these sta-
tistics, Sellenings states:
1. “Traumatic hernia is but a surgical curiosity
and assumes no practical importance. 2. Only a
small number of the cases have been carefully in-
vestigated. 3. A great proportion of the cases seem
to be relegated to the convenient classification of
‘vocational hernias.’ Whatever may be said of the
attitude of the New York Commission applied
equally well to many other sections of the country.”
One of the most recent and on the whole judicial
discussions of the subject Traumatic Hernia, or, as
the author terms it, “Compensable Hernia,” is con-
tained in a book on “Industrial Medicine and Sur-
gery,” by Harry E. Mock (Assistant Professor of
Industrial Medicine and Surgery at Rush Medical
College), published in 1919.
Mock calls attention to the fact that “the decisions
of established medicine date back to the precompen-
sation days and were based on the testimony of ex-
pert authority made in the courts of England es-
pecially, and later in our own courts, to the effect
that a traumatic hernia could only occur from a di-
rect violence resulting in a definite tearing or rup-
ture of the abdominal wall. All other hernias were
claimed to be due to congenital defects, preformed
sacs, and were similar to all other diseases which
might occur coincidental with occupation but ,.not
related to it. Such testimony was sustained by prac-
tically every court and their views were considered
as the decisions of established medicine.” He states
that, naturally few claims for traumatic hernia were
made, although employes in those days, just as fre-
quently as at the present time, blamed their work for
the condition.
The greatly increased number of claims for com-
pensation for hernia at present, he regards to be due
partly to the new attitude on the part of industry in
the direction of recognition of certain moral obliga-
tions as well as the realization that any improvement
in the condition of employes render them more use-
ful and more efficient. He states, that among broad-
minded employers, the question of whether there was
such a thing as traumatic hernia for which they could
be held legally responsible, caused little concern.
“They were not governed by the decision of estab-
lished medicine nor of established law but based their
decisions upon a just and good business sense. If
they employed a man with a hernia they knew the
industry was not responsible for it. If it grew grad-
ually worse without any definite accident or excessive
occupational effort it was due to natural causes and
again they were not responsible. But, if as a result
of accident or severe strain this hernia became stran-
gulated, at once doubt as to responsibility entered the
case and the decision was, therefore, rendered in
favor of the employes. If they hired a man who
showed no sign of rupture at his employment exam-
338
Journal of Iowa State Medical Society
[August, 1922
ination, but who later suffered an accident or a
severe occupational strain and as a result the hernia
appeared, compensation and free surgical care were
given, because in the man’s mind the accident caused
the trouble, and because they recognized that to a
certain extent the occupation was contributory to the
final development of the condition.
“From the standpoint of efficiency, it was found
that a man with hernia was about 25 per cent less
efficient than the man without one. Therefore, these
concerns might refuse to employ men with a rup-
ture but they became more and more liberal regard-
ing the repair of such a condition when it developed
in an old employe.”
Mock states that, “Such was the attitude of several
concerns at the time of the passage of the employes’
compensation acts. In fact those very laws were
an expression of this new humane influence which
had entered industry. The administration of these
acts were placed in the hands of industrial commis-
sions whose members were laymen rather than law-
yers. Influenced by the generous attitude of certain
industries, and guided by this sentiment and a con-
sideration of moral rights, combined with their
meager legal knowledge, the decisions of these va-
rious commissions were often at variance to those
rendered by the courts in the past.
“Thus employes began to seek compensation for
manv conditions which heretofore had not been con-
sidered compensable, and included among these were
hernias which developed during employment.”
Mock states, “The question of traumatic hernia,
therefore, simmers down to three considerations:
1. “A proper definition of what is meant by trau-
matic hernia.
2. “To what extent must an accident or an oc-
cupational hazard which only partially contributes
to the development of a condition be held responsible
for same.
3. “In which cases should compensation be paid
by the employer.”
Mock fully agrees with our own opinion and that
of practically all surgeons who have had much ex-
perience with hernia, that hernias as a result of di-
rect violence are very rare. He states that many of
the best authorities have enlarged the scope of trau-
matic hernia so as to include these cases which re-
sult from the indirect application of force causing
greatly increased intra-abdominal pressure. This
adoption of a broader definition, however. Mock be-
lieves would mean the inclusion of many additional
hernias in the compensable group, thus greatly con-
fusing the question. We believe it would be much
better to restrict the name of traumatic hernia to the
very small group limited to direct violence.
Other types of hernia for which the occupation is
more or less responsible, are described by Lotheissen
and other writers as “accidental hernia.”
Mock has personally observed only five cases of
true traumatic hernia due to direct violence at the
point where the hernia developed. He cites these
five examples as follows:
(1) “Man struck in the right groin by the sharp
end of a crow-bar; (2) a brakeman was crushed be-
tween the bumpers of two cars and a ventral hernia
appeared; (3) a man was running through the aisle
at fire drill and struck his left inguinal and scrotal
region against a truck handle. A large contused
area, swelling and hemorrhage into the scrotum im-
mediately followed. Within three daj'S a definite
left direct inguinal hernia appeared; f4) a pregnant
woman was kicked in her left lower abdomen by her
husband and very shortly a ventral hernia appeared
and naturally increased in size as pregnancy de-
veloped; (5) a cowboy came to my clinic with two
enormous oblique inguinal hernias. He gave a his-
tory of some two years previously having had a
horse he was riding rear and fall over backward, pin-
ning him beneath the saddle. The pommel of the
saddle had crushed into his lower abdomen. Imme-
diately there was bulging in both groins and these
continued until they had reached the present size
The man denied any sign of rupture previous to the
accident.”
In at least the fifth case of Mock’s series (enorm-
ous double oblique inguinal hernias) it would seem
almost certain that there must have been present
congenital sacs, or rather, an early stage of hernia on
both sides prior to the accident, and the enormous
increase in intra-abdominal pressure in this case
further developed the pre-existing condition. Mock
himself admits that, “It is quite evident that even in
those cases of inguinal hernia following direct vio-
lence, some doubt will always exist as to the possi-
ble presence of a congenital predisposition for
hernia.” He very truly affirms that, “Industrial com-
missions all over the country are depending on the
surgeons in industry to arrive at a just and equitable
decision concerning this subject of compensable
hernia.”
Mock believes that, “The first essential is to make
a careful physical examination of all employes and to
record those who have real or potential hernias.
Whenever a hernia develops in one of these em-
ployes who was recorded not to have a hernia a care-
ful analysis of his case must be made to determine
(1) Was it entirely due to pre-existing defect? (2)
Was it entirely due to some severe direct or indirect
violence? (3) Was a latent condition already pres-
ent and only aggravated by the unnatural occupa-
tional hazard? (4) Was it due entirely to natural
causes? (5) Or was it due to a combination of all
of these, and if so, which was the most responsible?”
Mock admits that, “The great majority of hernias
develop slowly, ‘the gradual dilatation of a preformed
sac.’ The congenital defect or predisposition is the
chief cause for such hernias and the relation of nat-
ural occupation or of the natural acts of ordinary
life are immaterial in their formation. These corre-
spond to the gradual development of ‘flat-foot,’ a
result of faulty shoes, constant standing and walking
or other natural causes; or to the development of tu-
berculosis in employes engaged in occupations which
in no wise predispose to this condition.”
VoL. XII, No. 8]
Journal of Iowa State Medical Society
339
MacCready, the greatest English authority on
hernia, states that an acquired hernia is never due to
an accident or single increase of intra-abdominal
pressure.
Graser, one of the highest German authorities,
states that a hernia complete in all its parts can
never arise at the moment of accident or by a single
increase in the intra-abdominal tension be it ever so
great.
Moschowitz of New York, who made a very care-
ful study of hernia in relation to the Workmen’s
Compensation Act (Med. Rec., Apl. 3, 1915), con-
cludes: “Traumatic hernia is exceedingly rare. It
may occur in any part of the abdomen, but usually
not at the site of the normal hernia openings. Work-
men’s Compensation Commissions are not and can
not be acquainted with all the facts relating to
hernia. This is evidently the sphere of the medical
profession; the Workmen’s Compensation Commis-
sion should be required to place implicit reliance
upon the decision of established medicine. In cases
of appeal from the decision of the Commission, all
the medical part of the testimony should be given
by experts of the court’s selection, and not of the
selection of the claimant or defendant.’’
A fact particularly emphasized by Hopkins is that
the great majority of hernias in industrial practice,
particularly in railroad work, are found in foreigners,
and nearly all in men who have not previously passed
a physical examination. One of the reasons why
they occur more frequently in foreigners is, we be-
lieve, the fact that the class of foreigners engaged in
the lower grades of railroad labor are, as a rule,
either undernourished at the time, or went through a
period of under-nourishment during childhood, which
tended to lessen the normal development of the ab-
dominal wall. Another reason for the higher per-
centage of hernias in foreigners, particularly those
coming from Russia and southern Europe, may be
found in the practice so widely prevalent among
these people, of trying to produce artificial hernia
in order to escape army duty. Doctor Gerster of
New York called attention to this factor many years
ago, and recently, at the Hospital for Ruptured and
Crippled, Doctor Hoguet observed a double direct
hernia, regarding which the man stated he had pro-
duced it himself. The method of production was:
Taking a hard, slightly blunted stick, placing it over
the inguinal canal and then striking moderate blows
from time to time with a mallet until the muscular
structures in the neighborhood of the canal are torn
or pu.shed to one side and finally a hernia develops.
Here again we must observe that it does not occur
as the result of a single blow or single injury; it is
only the repeated blows with this more or less sharp
instrument that finally produces such a weakness as
to cause a direct hernia to follow.
Of all the attempts made by the different State
Commissions to solve this vexed problem of trau-
matic or industrial hernia, the industrial commis-
sions of Nevada and California stand out as most
in accord with our present knowledge of the causes
of hernia. The following is a ruling of the Cali-
fornia Industrial Commission:
“The consensus of medical and surgical opinion
runs to the effect that hernia is very rarely, in any
proper sense, the result of an accidental injury, that
the accident is at best no more than the occasion in-
stead of the cause of the malady; that the origin of
the difficulty is congenital and more in the nature of
a disease than an injury; that every claim for com-
pensation based upon an alleged rupture is to be
viewed with suspicion.”
The Nevada Commission rules:
“Medical science teaches now what it has taught
for the past twenty years and is now accepted as a
medical and scientific truth, corroborated as such by
the fore'most surgeons and anatomists in the world;
that is, that hernia, or so-called rupture, is a disease,
ordinarily developing gradually, and is very rarely
the result of an accident.”
The following rules have been promulgated by the
Nevada Commission:
“Rule I. Real traumatic hernia is an injury to the
abdominal wall (belly wall) of sufficient severity to
puncture or tear as under said wall and permit the
exposure of protrusion of the abdominal viscera or
some part thereof. Such injury w'ill be compensated
as temporary total disability, and as partial perma-
nent disability, depending upon the injured individ-
ual’s earning capacity.
“Rule II. All other hernias, whenever occurring
or discovered and whatsoever the cause, except as
under Rule I, are considered to be diseases, causing
incapacitating conditions or permanent partial dis-
ability and the causes of such are considered as
shown by medical facts to have either existed from
birth, to have been years in formation, or both, and
are not compensatory, except as provided under
Rule III.
“Rule III. All cases coming under Rule II, in
which it can be conclusively proved, first, that the
immediate cause which calls attentioij to the presence
of the hernia was sudden effort or severe strain or
blow received while in the course of employment;
second, that the descent of the hernia occurred im-
mediately following the cause; third, that the cause
was accompanied or immediately followed by se-
vere pain in the hernial region; fourth, that the
above mentioned facts were of such severity that
they were noticed by the claimant and communicated
immediately to one or more persons are considered
to be a.ggravations of previous ailments or diseases,
and will be compensated as such for time or loss
only, depending on the nature of the proof submitted
and the result of the local medical examination.”
The Committee is entirely in accord with Rules I
and II of the Nevada Commission. It, however,
calls attention to a serious conflict in Rule III of the
second proof, which must be given in order to es-
tablish a right for certain compensation. Rule II
states specifically that by medical facts it is shown
that a hernia either exists from birth or is years in
formation; whereas, in the second proof of Rule III
340
Journal of Iowa State Medical Society
[August, 1922
it speaks of a descent of hernia occurring imme-
diately following a strain or blow. This assumes
that hernia may be the result of a single increase of
abdominal pressure which the Commission in Rule II
stated to be impossible.
Man)- writers state that a recent hernia is tender
and painful on manipulation, and ecchymosis is not
infrequently present. This statement is frequently
found in text-books and particularly in articles upon
Traumatic Hernia. We believe it has no basis in
fact. In an experience of thirty-one years at the
Hospital for Ruptured and Crippled, where we have
an average of 5,000 new cases a year, there has not
been a single case of recent hernia which was “ten-
der, painful and accompanied by ecchymosis” in
which there had been a history of antecedent injury
or accident of any form. We have seen a number of
cases that were attributed to an injury, and we are
of the opinion that the patients honestly believed
that the injury was the cause of the hernia; yet the
size of the hernia ring, the thickness of the sac, with
adhesions to the surrounding structures, all proved
beyond the shadow of a doubt that the hernia was of
long standing, although probably not previously rec-
ognized by the patient. A recent case, only observed
in October, 1921, is a very good illustration of this
point: A man, twenty-five years of age, employe of
the Xew York Central Railroad Company, with a
history of never having had any swelling whatever in
the region of the hernial canals, shortly after heavy
lifting noticed a swelling in the right inguinal re-
gion. He came to the Emergency Hospital of the
X. V. C. R. R. Co., where the attending surgeon
found a well-marked inguinal hernia, the size of a
small egg, in the right inguinal region, extending
well into the canal and upper scrotum. In the
opinion of the surgeon, this was one of the most
definite cases in his experience pointing to a casual
relationship between the strain and the hernia, and
it might have been so regarded had not the patient
consented to an operation. On October 14, 1921,
Doctor Coley operated and found a preformed sac
undoubtedly of congenital origin, extending well into
the upper scrotum, 2}^ inches long and 2 inches
broad, considerably thickened, firmly adherent to the
overlying cremaster muscle. The nature of the sac
clearly proved it to be of congenital origin and in
all probability the hernia itself had existed for
months or possibly years, although the patient may
never have recognized it until the time of the un-
usual strain, when a somewhat larger amount of
omentum or bowel was forced into the sac, causing
slight pain which first called his attention to the
hernia.
Hernia is practically always due, first, to the pres-
ence of a preformed sac or open pouch of peritoneum
■which, in the inguinal variety, follows the testis in
its descent into the scrotum, which pouch has failed
to close in the normal way; and, second, to the
presence of structural •weakness in the neighborhood
of the hernial orifices due to poorly developed mus-
cles or fascia. Given these all important anatomical
causes which are in themselves sufficient in many
cases to constitute a potential hernia, the actual
hernia may develop by reason of a great variety of
exciting causes; among these may be mentioned the
daily increase in intra-abdominal pressure incident to
the ordinary routine of life, e. g., straining at stool,
coughing, sneezing, lifting, etc. The main point that
can not be emphasized too strongly is that the hernia
is never the result of a single strain or single in-
crease in intra-abdominal pressure due to any of the
causes mentioned; on the other hand, it is the cumu-
lative effect of a great number of strains spread over
a considerable period of time. In nearly all cases
hernia is of gradual onset, and is rarely accompanied
by pain, and most frequently remains unnoticed until
it has reached a considerable size or until some acci-
dent or strain by slightly increasing the contents of
the hernia sac causes it to be noticed for the first
time. Hence, the accident or strain is usuallv the
occasion which first attracts the attention to a hernia
long present but hitherto undiscovered. It has been
a matter of almost daily observation at the Hospital
for Ruptured and Crippled to find a patient applying
for a truss or for operation for a hernia on one side,
when careful examination discloses the fact that he
has a hernia on the other side, almost if not as large
as the one for which he applied for treatment. The
size of the hernia and the character of the sac as
determined by operation prove beyond question that
this hernia existed for a long period and was quite
unrecognized by the patient. Hence, it is true, that
in many cases a person who claims that his hernia is
due to an accident or injury may sincerely believe
this is to be that fact, because he was unaware of the
presence of a swelling prior to the accident, al-
though it had really existed for months or years
before. In many cases, however, the contrary is
true and claim for indemnity or large damages is
made upon a corporation for a hernia which the
claimant well knew had existed for a long period
prior to the accident. In some cases, evidence of
his having worn a truss for a long period of time is
apparent. We have seen many cases of this type in
our medico-legal work and in some instances the
sympathetic jury has awarded very large damages
In all of our experience we have never seen a single
case in which there was any sound basis for the
claim that the accident or injury was the cause of
the hernia. In many cases the jury has been con-
vinced by expert testimony that a hernia could not
have been caused by the accident mentioned and have
rendered a verdict accordingly; but on the other
hand, in other cases, all of the expert evidence has
beeen brushed aside and the jury has allowed its
sympathy for the claimant to outweigh the seemingly
slight loss of a few thousand dollars compensation
to the supposedly wealthy corporation. One case
which we recall is that of a man of about fifty years
of age, who claimed to have been thrown forward
against the back of the seat in front of him in a slight
collision. The slight increase in intra-abdominal
pressure was made the basis for his claim that a
VoL. XII, No. 8]
341
Journal of Iowa State Medical Society
large double inguinal hernia was the result of the
accident, although there was no evidence of local in-
jury at the site of either hernia. In spite of expert
evidence to prove the fact that a double hernia is
never the result of trauma, that these hernias were
both too large to have been of recent origin, the
jury awarded very large damages ($15,000). How-
ever, the verdict was so palpably against the evi-
dence that the decision was reversed by the Supreme
Court.
-\t present the situation in regard to dealing with
the question of traumatic or industrial hernia maj'
be described as chaotic. There are, however, a few
states in which the members of the Workmen’s Com-
pensation Commission apparently have made a scien-
tific study of the subject before formulating any
rules and in these states the subject is treated in a
most fair-minded and judicial way; in other states,
however, the rulings are apparently based on the
old and long-discarded ideas as to the etiology of
hernia, with the result of great financial loss to the
interested corporations and in the end distinct harm
to the individuals.
What, then, is the remedy? The only thing needed
to bring about greater harmony in the procedure of
industrial commissions is to spread broadcast a
clearer knowledge of the well-known medical and
surgical facts relating to the etiology of hernia. We
must recognize that medical and surgical truths per-
meate but slowly, especially when they have to over-
come long established traditions too often supported
bv court decisions. The first is to convince the com-
missions and the courts of the well-established sur-
gical fact that hernia is a disease and not the result
of an accident. When this has been done a radical
review of the present state laws regarding compen-
sation in cases of industrial hernia will be forth-
coming.
Recommendations
1. Render proper compensation for all cases of
true traumatic hernia due to direct violence.
2. Make a physical examination of all applicants
for positions in industry no matter in what capacity;
such examinations will determine the fact whether
or not a hernia was present at the time of examina-
tion.
3. Any case of hernia developing in the course
of duty, incident to the man’s daily work, should be
treated as a disease due to special anatomical weak-
ness on the part of the individual, for which the com-
panv is in no way responsible. If it is considered
wise under certain circumstances to recognize any
moral responsibility, let it be on an economic or
humane basis. This moral obligation should be un-
derstood to be strictly limited to such employes who
had been found apparently free from hernia at the
time of previous physical examination.
Respectfully submitted.
Committee on Traumatic Hernia.
BIBLIOGRAPHY
Berger. Rev. de Chirurgie, 1906. Nos. 4 and 5.
Kocher. Correspondenablatt f. Schwitz. Aerzte, 28, 1893.
Von Hassel et Walraveus. Jour, de Chirurgie, Bruxelles, 126,
190:5.
Forgue et Jean Brau. .\ccidents du Travail, Paris, 190.5.
Berger. Traite de Chirurgie (Masson et Cie.) Duplay et
Reclus Vol. VI.
Kingdon. Med. Chir. Transactions, L864, p. 286. 296.
Murray. Lancet, April 20, 1907.
Roberts. N. Y. Med. Jour., 1904, Vol. LXXX, p. 631.
Hamilton Russell. Lancet, 1904, p. 707. Ibid., 1907.
Blasius. Verhandl. d. Gesellsch. Deut. Naturf. u. Aertz., 1895,
LXVI.
Stuki. Correspbl. f. Schweitz, Aerta., 1899, p. 589.
Sultan. Abdominal Hernia. (Saunders) Coley & Satterwhite,
International Jour, of Surgery, Feb., 1904.
Gallaudet. Med. and Surg. Reports of Bellevue Hosp., 1904,
Vol. I.
Hernie Consideree Comme Accident des Travail. Jour, de
Med. de Paris 1907, 2, S. XIX, 53.
Lucas Championniere. Jour, de Med. et de Chir. prat., 1906,
LX.XVII 6.
Reclus. Clinique Paris, 1907, LL 249.
Butte. N. Y. Med. Jour., Oct. 19, 1907.
Cutten Witthaus & Becker’s Med. Jurisprudence, Forensic Med-
icine and Toxicology, 1907, p. 853.
Daget. Le Hernie est elle accident du travail. Theses de
Paris, 1905.
Graser. Handbook of Practical Surgery, 1900, Vol. XX, p.
826.
Hopkins. International Journal of Surgery, January, 1921.
Lotheissen. Arch. f. Orthop. Mechanotherap. u. Unfallchirurg.,
1906, bd. LV.
MacCready. Treatise on Ruptures. (Blakiston.)
Mock. Industrial Medicine and Surgery. (Saunders.)
Moschowitz. Medical Record. April 3, 1915.
Sellenings. N. Y. Medical Journal. April 24, 1920, p. 713.
Sheen. Practitioner. London, 1909.
Duchamp. La hernia au point de vue me legal. Loire medic.
St. Etienne, 1900, p. 258.
Gazette medicale de Paris, 1901, p. 170.
Jazquet. Echo med. du Nord., 1900, p. 500.
Janin. Theses Paris, 1902.
Loriot. Theses Paris, 1902.
De Quervain. De la hernie de force, Semaine medicale, 1900,
p. 87.
Socin. Chr. Bl. f. schweiz, Aerzte. Bezel, 1887, p. 545.
Sole. J. de Med. de Paris, 1904, p. 27.
Coley. International Journal of Surgery, February, 1908.
Coley. International Journal of Surgery, February, 1904.
Coley. Keen’s Surgery, Vol. IV.
REPORT OF RECOMMENDATIONS OF THE
AMERICAN RAILWAY ASSOCIATION
IN CONNECTION WITH HOSPITAL
STANDARDIZATION
I have been requested to speak to you this morn-
ing on what the railroads have been doing in con-
nection with this program of standardization. And
in order that you may form some idea and reach
some conclusion as to just what we will be able to
do to assist in this movement, I think it might be
well to spend a minute or two on the question of
what the organization is that I am speaking for.
The American Railway Association is an organiza-
tion made up of the presidents and managers and
operating officials of the various railroads through-
out the country that are members of this Associa-
tion. The Association membership comprises about
two hundred and eighty-four thousand miles of rail-
road in the United States and Canada, and you will
therefore see that practically every railroad in the
country is a member of this Association.
The Association itself is conducted in the follow-
ing manner: It has its own president and its general
secretaries and secretaries of sections. The operat-
ing officials of the American Railway Association,
the men who pass upon the recommendations made
by the various sections of the Railway Association,
are the general managers and the president and vice-
president of the railroad, and while the action of
342
Journal of Iowa State Medical Society
[August, 1922
the American Railway Association itself is not com-
pulsory or mandatory, it becomes a forceful action
as a recommendatory practice because the very men
who are called upon to accept the recommendation
of the American Railway Association are the men
who have favored such action.
The American Railway Association has numerous
sections. It is needless for me to go into details in
regard to them. Our section is the medical and
surgical section and this section comprises, or is
made up of, the railway and surgical chiefs of these
various railroads that are members of the Associa-
tion. This section was first incorporated in the
American Railway Association about a year ago.
And one of the first actions of the committee of that
section was to take up the question of hospital stand-
ardization, because the railroads felt that it was im-
perative that our employes injured in service must
get all possible care and attention.
The committee on hospital standardization dis-
cussing this subject made the following recommen-
dation through its chairman. Dr. A. F. Jonas of the
Union Pacific Railroad:
“The medical and surgical section committee on
hospital standardization held a meeting at Chicago
on April 6, 1921. In accordance with its understand-
ing of its purpose, it has adopted the minimum stand-
ard as the basic recommendations for the railroads of
the Association.”
The recommendation of the committee was ac-
cepted and it was submitted to the various members
of the sections, who unanimously approved it and on
the sixteenth of November it will be submitted to
the annual session of the American Railway Asso-
ciation, and I have no doubt in the world will be
approved.
Now, this will mean that the railroads through
their surgical service will take the position that they
will have their men treated in hospitals that meet
with the minimum standard of the American College
of Surgeons. You appreciate as well as I that a
large amount of our work is of an emergency char-
acter and that, therefore, we cannot always be
choosers. There will be times when we will have
to put men in a hospital that has not adopted the
minimum standard for hospitals. But it is our in-
tention wherever it is practicable to remove those
patients from such hospitals and put them in a
hospital having the minimum standard just as soon
as consistent with safety to the patient. I do not
know but what it is a pretty good thing to follow
that up even a little bit closer than that. I am
sure that in a number of instances the transporta-
tion of a man seriously injured — crushed leg, we will
say — for a greater distance to a better hospital would
be giving that man a greater opportunity for re-
covery than putting him in a hospital that was not
up to the standard in its work.
Great Impulse to Standardization Movement
We have in the railroads about thirteen thousand
doctors and students acting in the capacity of sur-
geons for the railroads. And we have about 275 or
280 men who are members of surgical staffs. And
with the railroads taking this position, I believe that
it will be a tremendous factor in assisting the bring-
ing of standardization over a larger field.
I cannot give you the exact or even the approx-
imate number of hospitals that are used by the
railroads. I hoped to be able to get that but I
could not. I know that the Baltimore and Ohio
uses about 310. The Pennsylvania railroad uses
about 277 hospitals. The Union Pacific, on the other
hand, a railroad of about nine thousand miles, or
three thousand four hundred miles larger than the
Baltimore and Ohio, uses only about 123. The Union
Pacific has twenty hospitals that are under its own
control, at least that they contract with. The other
hospitals are hospitals that they have used from time
to time in emergency.
The railroads use four-fifths of the hospitals of
the country, and while of course a large number
of the hospitals have already reached the minimum,
still there is a very large field which will be affected
by this position of ours, and I can assure you the
doctors of the American Railway Association are go-
ing to take the position not verbally but actively. —
Daniel Z. Dunott, M.D., Baltimore, Chairman, Med-
ical and Surgical Section, American Railway Asso-
ciation.
The Rockefeller Foundation announced that the
International Health Board has accepted an invi-
tation to cooperate in carrying out the general
scheme of reorganization of the public health activ-
ities of the Philippine Islands, which was recently
made public by the president of the senate, Manuel
Quezon.
The participation of the board will consist in lend-
ing the services of certain members of its staff for a
limited period and providing specialists as consult-
ants and assistants to Philippine government offi-
cials in various lines of public health work. The
broad program which the government has adopted
for improving health conditions includes the ultimate
consolidation of all health functions in a single de-
partment of health to corespond with the ministry
of health in other countries.
Among the persons whose services will be fur-
nished by the Rockefeller Foundation is an assistant
to the dean of the College of Medicine and Surgery
of the University of the Philippines, who will assist
in developing the medical school and will give par-
ticular attention to the problem of providing post-
graduate instruction in public health so that the
health workers so urgently needed in the Philippine
Islands may be trained locally.
Fellowships for advanced study in the United
States will be offered by the board to exceptionally
promising and well qualified young Filipinos, to fit
them for the more important administrative and
technical positions in the public health service and
for positions as instructors in the College of Medi-
cine and Surgery and as teachers of nursing.
VoL. XII, No. 81
Journal of Iowa State Medical Society
343
Existing facilities for the training of nurses are in-
adequate to meet the demand for hospital and private
service. The nursing situation will therefore be
studied and special attention given to training women
in public health nursing.
As one important part of the plan, an assistant
will be provided for the Director of the Bureau of
Science, who will be expected to advise in the further
development of that Bureau, which has already made
notable contributions to various scientific problems.
The Biological Laboratory, which is one department
of the Bureau of Science, is to be expanded in order
to serve as the central public health laboratory of
the Philippines, with local laboratories in the
provinces.
Dr. Victor G. Reiser, director for the East of the
International Health Board, and formerly director
of health for the Philippine Islands, will go to
Manila to assist in carrying out the program.
MALPRACTICE CASES IN NEW YORK
Analysis of malpractice cases receiving counsel’s
attention between April 1, 1921 and March 15, 1922, is
set forth in detail in a table. It appears that on
April 1, 1921, there were pending sixty-nine such
cases and since that time there have been forty new
cases instituted and thirty-seven disposed of, so that
there are pending on March 15, 1922, seventy-two
cases, an increase of three cases over the number
pending a year ago. The table likewise shows that
there is a larger percentage of such cases brought
against general practitioners than against specialists.
Thus of the cases pending on April 1, 1921, over
74 per cent were against general practitioners and
of the new cases instituted since that time 58 per
cent were against general practitioners.
THE SCHICK REACTION*
Monthly Bulletin Issued by the Laboratory of
Pathology and Bacteriology, Finley Hospital,
Dubuque, Iowa
Schick in 1913 published the method by which the
presence of diphtheria antito.xin in the blood and
tissues can be determined. He injected a minute
quantity of diphtheria toxin intracutaneously and a
local reaction followed if there was less than 1-30
of a unit of antitoxin per c.c. of blood. The latter
amount is considered sufficient to protect against
diphtheria. The explanation of the test is that when
no antitoxin is present, the toxin acts on the skin:
when antitoxin is present it neutralizes the toxin so
no poisoning results, or in other words — a negative
reaction indicates the presence of antitoxin. A posi-
tive reaction indicates that the patient is susceptible
to diphtheria.
The Technique of the Test
The injection is made on the flexor surface of the
‘Acknowledgment — The statements in this article are largely
based on the published work of Dr. William H. Park and his
associates of the New York City Department of Health.
forearm or arm, which should be cleansed with soap
and water and allowed to dry. A fresh solution of
diphtheria toxin is prepared and should be of such
strength that 0.2 c.c. represents 1-50 of the minimum
lethal dose of toxin for a 250 gram guinea pig. This
amount is injected with a good syringe which has a
fine steel of platinum-iridium needle intracutan-
eously. A good guide for the insertion of the needle
into the proper layer of skin, is to be able to see the
oval opening of the needle through the superficial
layers of the epidermis.
A properly made injection is recognized by a dis-
tinct wheal-like elevation which shows the promi-
nent openings of the hair follicles. The results of
the test should be read at the end of 24, 48, 72 and
96 hours.
Type of Reaction
The reaction that appears at the site of injection
may be either (1) positive, (2) negative, (3) pseudo,
or (4) combined positive and pseudo.
(1) The positive reaction represents the action
of the toxin on tissues unprotected by antitoxin. It
indicates, therefore, an absence of immunity to diph-
theria. A trace of redness appears slowly at the site
of injection in from 12 to 24 hours. The reaction
reaches its height on the third or fourth day and
gradually fades leaving a definite circumscribed area
of redness and slight infiltration measuring 1 to 2
cm. in diameter. The degree of redness and infil-
tration varies to some extent, depending on the rela-
tive susceptibility of the patient.
(2) A negative reaction is one in which the skin
at the site of injection remains normal. Provided
the toxin w’as of full strength and that the injection
was in the proper layer of skin, it means that the in-
dividual is immune to diphtheria.
(3) The pseudo reaction represents a local ana-
phylactic response of the tissue cells to the protein
substance of the autolyzed diphtheria bacilli, which
is present in the toxic broth used for the test. It is
of urticarial nature; appears early — 6 to 18 hours;
reaches its height in 36 to 48 hours, and disappears
on the third or fourth day. The reaction may be
tw'o or three times the size of a true reaction. In
doubtful cases a control test, made by injecting
Toxin-Antitoxin heated to 75 degrees Centigrade for
five minutes gives a similar reaction which passes
through the same clinical course. Individuals giving
the pseudo-reaction only, are immune to diphtheria.
The false reactions are seen in relatively few chil-
dren, but does occur fairly frequently in adults. It
is, therefore, important to recognize and control it
both by the injecting the heated toxin and observing
the clinical course of the reaction.
(4) The combined reaction represents the positive
and pseudo-reactions in the same individual. The
central area of redness is larger and better defined
while the infiltration is more marked. The reaction
is recognized by noting the evidence of a true re-
action, a definite area of scaling, brownish pigmenta-
tion after the pseudo element has faded. In addition
344
Journal of Iowa State Medical Society
[August, 1922
a smaller, though weaker, reaction is obtained by a
control test made with heated toxin. The control
represents only the pseudo-reaction. The combined
reaction indicates absence of immunity to diphtheria.
Results of Tests in New York
Dr. Park and his associates who have used the test
extensively in this country, state that their result
closely parallel those of Schick. They found that a
large number of individuals are naturally immune.
They publish the following;
Summary of Schick Tests Showing Maximum and
Minimum Percentage of Schick Reactions
% Positive
Schick
1 to 2 years 50 to 70
2 to 4 years 32 to 60
4 to 6 years 25 to 55
6 to 8 years 21 to 55
8 to 10 years 22 to 55
10 to 12 years 21 to 55
12 to 14 years 17 to 50
14 to 16 years 16 to 50
16 to 30 years 15 to 40
From these figures they state that it is evident that
it is in the first five years of life that the greatest
susceptibility exists. This corresponds to Schick’s
findings as he reported positive reactions in 7 per
cent of the new born, in 43 per cent during the second
six months of life, in 60 per cent in the first five
years of life, and in 50 per cent between five and
fifteen years.
Use of Toxin- Antitoxin in Immunization Against
Diphtheria
Behring first used Toxin-Antitoxin mixtures for
the immunization of children against diphtheria. For
several years the health department of New York
City have been using the mixture and recently re-
ported their results for a period of five years. Sev-
eral thousand children were immunized after having
been found susceptible to diphtheria by the Schick
test. The Toxin-Antitoxin mixture used contained
2 L plus doses of toxin to each cubic centimeter and
were either neutral (66-70% L plus to each unit of
antitoxin) or slightly toxic (80-90% L plus to each
unit of antitoxin) to the guinea pig. The doses
varied from 0.5 to 1 cubic centimeter and the number
of injections from one to three. Three injections of
1 cubic centimeter made subcutaneously at intervals
of seven days gave the best results. The local re-
actions were generally mild but were somewhat more
marked in older than in younger children. Malaise
and temperatures of 100 to 102 degrees Fahrenheit
were noted in about 20 per cent of the cases. Rarely
the temperature dose to 104 degrees Fahrenheit. The
symptoms lasted from twenty-four to forty-eight
hours and then subsided. Superficial abscesses de-
veloped in twelve cases but cleared up quickly.
The re-tests with the Schick reaction showed only
30-40 per cent immune three weeks after the first in-
jection, about 50 per cent at four weeks, 70-80 per
cent at six weeks, and 85-90 per cent at eight to
twelve weeks. Studies show that the immunity per-
sists for five years and may be indefinite.
Park and Zingher conclude that it is advisable to
immunize children soon after the first year of life,
so as to afford them a protection against diphtheria
during the dangerous years. These children have no
hypersensitiveness to the bacillus protein and show
mild local and constitutional symptoms. They be-
lieve that an immune child population could thus be
developed and fresh cases would be prevented and
the carrier menace would soon disappear. They
furthermore point out that by the use of the Schick
reaction a goodly proportion of children will not have
to have the usual prophylactic dose of antitoxin when
exposed to diphtheria. In the light of modern serum
therapy this is no small matter as sensitization to
horse serum is thus prevented. That immunization
may be started very early is evidenced by the fact
that in their series, 2,000 infants, none over one week
old, w'ere injected. No ill effects were noted in a
single case. Eighty per cent remained immune after
the time the passive immunit}" derived from the
mother usually disappears.
Conclusions
The Schick test determines an individual’s suscep-
tibility or non-susceptibility to dipththeria.
Sensitization of a goodly percentage of the public,
with the usual prophylactic dose of antitoxin, can be
prevented b}^ first finding out if individuals are sus-
ceptible to diphtheria or not.
Immunity to diphtheria for at least five years and
possibly indefinitely, is conferred by injections of
Toxin-Antitoxin mixture.
It may be hoped that with the vigorous use of these
new weapons diphtheria will cease to be the great
scourge of childhood.
RADIUM IN CONGO
The Scalpel of Brussels quotes the bulletin of the
Belgian Chemical Society to the effect that the sam-
ple of minerals from the Congo assayed by Professor
Schoep of the University of Ghent yield 424 kg. of
uranium and 139 mg. of radium to the ton. The min-
erals came from the Upper Katanga, in the conces-
sion of the Union Miniere which has entrusted the
industrial treatment of the uranium to the Belgian
Societe Generale Metallurgique de Hoboken, which
has put up a factory for the purpose in the Antwerp
district. Other deposits of the same minerals have
been found at other points specified, and Professor
Schoep has found two new kinds of minerals among
them, extremely radioactive. He has named one
“curite” and the other kasolite,” and announces that
the crystals are soluble in nitric acid, and the radium
salt can then be extracted from the fluid without
passing through the usual calcination process. —
Journal of A. M. A.
345
Journal of Iowa State Medical Society
VoL. XII, No. 8]
IOWA STATE UNIVERSITY NEWS NOTES
Dr. Don M. Griswold
Dr. Hannan L. Stanton and Dr. C. C. Jones, as-
sistants in the department of ophthalmology, oto-
laryngology and oral surgery. State University of
Iowa, have located in Des Moines where they will
practice their specialty, eye, ear, nose and throat.
Dr. F. C. Nilsson, assistant in the department of
ophthalmology, oto-laryngology, and oral surgery.
State University of Iowa, has accepted the position
as instructor in the same department, Dr. Dean’s
department.
Dr. H. P. Miller, resident physician in the depart-
ment of surgery, has gone into partnership with Dr.
C. T. Foster of Rock Island.
Dr. Harry T. Dunn, assistant in the department
of gynecology and obstetrics has gone into private
practice at Bristow. Iowa.
Dr. Herbert Reuling of the department of oph-
thalmology, oto-laryngology and oral surgery, has
located at Waterloo where his practice will be lim-
ited to his specialty, eye, ear, nose and throat.
Dr. W. T. Vandesteeg, resident physician in the
department of gynecology and obstetrics, has ac-
cepted a position as mining surgeon in Biwaki, Minn
Dr. Gideon J. Ferriera, hospital chemist of the
State University Hospital has gone into practice at
Aurora, Minnesota.
Dr. Harry W. Dahl, lecturer in clinical microscopy,
department internal medicine, has accepted a posi-
tion in the Hospital of the Rockefeller Institute for
Medical Research, New York City.
Dr. Edgar Medlar, acting head of the department
of pathology and bacteriology and hospital path-
ologist, the past year, has accepted a position with
the Metropolitan Life Insurance Company and went
to his new position at Mount McGregor}-, New York,
August 1, 1922.
Dr. Frank Peterson, assistant in the department of
pathology and bacteriology, has accepted the position
as assistant in surgery in the department of surgery.
College of Medicine, State University of Iowa.
A public health conference for health officers,
nurses, and sanitarians, was conducted under the
auspices of the extension division of the State Uni-
versity and the state board of health, at the Univer-
sity of Iowa, on the 18, 19, 20 and 21st of July.
SOCIETY PROCEEDINGS
Dubuque County Medical Society
Dr. George W. Hall and Dr. Frank Smithies, both
of Chicago, and Dr. F. H. Falls of the State Univer-
.sity of Iowa City were among the visiting speakers
on the morning and afternoon programs of Dubuque
County Medical Society, June 27, 1922.
■At 6:30 in the evening the annual banquet was held
at Leiser’s in Sageville. Dr. Mary Killeen was toast-
master.
Morning Session, 9 to 12 — P'irst Congregational
Church, 10th and Locust streets.
Neurologic Clinic — Dr. Geo. W. Hall, Chicago.
Diagnostic Clinic Internal Medicine — Dr. Frank
Smithies, Chicago.
Clinic on Dermatology — Dr. W. A. Pusey, Chicago.
■Afternoon Session, 2 to 5:30 — First Congregational
C'hurch, 10th and Locust streets.
Interpretation Wassermann Reaction — Dr. Frank
P. McNamara, Dubuque.
Treatment Syphilis — Dr. W. .A. Pusey, Chicago.
Clinical Procedures Available for the Detection of
Liver and Bile Tract Disease (with lantern slides) —
Dr. Frank Smithies, Chicago.
Teleordiography of the Heart — Dr. W. A. John-
ston, Dubuque.
Modern .Aspects of Cesarean Section — Dr. F. H.
Falls, State University, Iowa City.
The Diagnosis and Management of .Acute Cranial
Injuries — Dr. Harry Jackson, Chicago.
Dr. Killeen is president of the county organization,
and Dr. H. E. Thompson, secretary. Program com-
mittee is comprised of Doctors C. E. Lynn, Walter
Cary, J. E. Calhoun, H. B. Gratiot, J. C. Hancock,
H. E. Thompson and O. E. Haisch.
Greene County Medical Society
The Greene County Medical .Society held its quar-
terly meeting. May 17th, at the home of Dr. and Mrs.
Cressler, Churdan. .A seven o’clock dinner was
served to the members and their wives. The meet-
ing was called to order by President, Dr. Reed, of
Grand Junction. Dr. Franklin of Jefferson, gave his
report as delegate to the Iowa State Medical Society
at Des Moines, May 10.
Marion County Medical Society
The fiftieth anniversary meeting of the Marion
County Medical Society was held in Knoxville,
Thursday, June 22.
In the afternoon, the doctors and dentists met in
scientific session at Auld Park, the following pro-
gram was rendered:
Diagnosis of the .Acute Abdomen — J. W. Martin,
M.D., Des Moines.
Our Relationship from the Dental Viewpoint — W.
L. Harlan, D.D.S., Knoxville.
History of the Pella Typhoid Epidemic of 1920 —
C. F. .Aschenbrenner, M.D., Pella.
While the medics and dents were indulging in their
346
Journal of Iowa State Medical Society
[August, 1922
shop talks, the wives of the local doctors with Mrs.
Magarian as hostess, entertained the visiting ladies
at a reception.
In the evening a banquet was served by the camp-
fire girls at the K. P. hall under the supervision of
Mrs. H. L. Bridgman. After the inner man was
served a very interesting program of toasts, im-
promptu talks, recitations and vocal and musical
numbers was rendered. Dr. Carl Ashenbrenner of
Pella presiding as toastmaster. Sixty-five doctors,
dentists, their wives and guests were in attendance.
Prominent among those present from outside the
county were, Dr. and Mrs. Martin, Dr. Holbrook,
Dr. King, and Dr. Huston of Des Moines; Dr. San-
ford of U. S. Veterans’ Hospital No. 75 of Colfax
and three of his staff; Dr. and Mrs. Brittell of
Chariton; Dr. Taylor, Dr. and Mrs. Payne of Mon-
roe; Dr. and Mrs. Ayres of Leighton.
The Marion County ^ledical Society was organ-
ized January 8, 1872. The charter members were Drs.
A. D. Wetherall, N. R. Cornell, W. E. Wright, S. A.
Duncan, H. J. Scoles, W. T. Baird, T. W. Mitchell,
and E. Williams, none of whom is living. Since its
origin the society has been twice re-organized, once
in 1900 and again in 1903. Under the latter date a
charter was granted by the State Society, the local
association being recognized as one of its component
units. At present the number of physicians of
Marion County numbers twenty-six, eighteen are
members in good standing of the county society.
C. S. Cornell, Sec’y.
Page County Medical Society
At a meeting of the Page County Medical Society
held at the Hand Hospital a number of physicians
were present from Clarinda, Yorktown and Essex
as well as the local members of the society. Cases
were presented and discussed by the Shenandoah
doctors. The next meeting will be the annual ses-
sion at Clarinda the first Thursday in December.
Those present from out of town at the meeting
were: Dr. P. E. Bowers, Dr. R. J. Matthews, Dr. W.
D. Phillips, Clarinda; Dr. C. C. Patriott, Essex and
Dr. T. F. Benning, Yorktown.
Van Buren County Medical Society
In honor of Dr. G. R. Neff of Farmington, and Dr.
T. G. McClure 'of Douds, two veteran physicians of
Van Buren county, the Van Buren County Medical
Society gave a banquet at Hotel Manning, at which
the rhembers of the society and their wives were
present. The occasion was in the nature of a golden
anniversary for the two senior physicians. Dr. Neff
having been engaged in the practice of medicine
fifty-two years; Dr. McClure forty-seven years. Both
men are still in active practice and both men have
spent all their professional life in Van Buren county.
At present Dr. T. G. McClure is president. Dr. G.
R. Neff, vice-president of the medical society and Dr.
C. R. Russell of Keosauqua, secretary and treasurer.
Wall Lake District Medical Society
I he Wall Lake District Medical Society, com-
prising Ida, Sac, Crawford, Carroll and Calhoun
Counties, met at the Opera House, Wall Lake,
June 22.
The Program was as follows: Afternoon Session.
1:30 p. m. — Meeting called to order by President J.
H. Stalford, Sac City.
■Address of W’elcome — Mayor E. R. Frazier.
Response — Dr. F. E. Kauffman, Lake City.
Ruptured Liver — Dr. F. H. McCray, Schaller. Dis-
cussion opened by Dr. E. S. Parker, Ida Grove, and
Dr. G. Hartley, Battle Creek.
Obstetrics in Ida County During 1921 — Dr. C. S.
Stoakes, Battle Creek. Discussion opened by Dr.
G. C. Moorehead, Ida Grove, and Dr. Grubb, Galva.
Confusing .Abdominal Symptoms Produced by Dis-
eases of the Chest — Dr. D. H. Hopkins, Glidden.
Discussion opened by Dr. W. M. Shirley, Carroll,
and Dr. D. J. Townsend, Lohrville.
Purpura Haemorrhagica, with Presentation of
Case — W. E. McCrary, Lake City.
-A Case of Purpura Haemorrhagica — Dr. H. D.
Jones, Schleswig. Discussion on the two last named
papers opened by Dr. G. H. Swearingen, Sac City,
and Dr. H. L. Fobes, Auburn.
Treatment of Pulmonary Tuberculosis by X-Ray,
and Actenic Ray — Dr. O. W. Wyott, Manning. Dis-
cussion opened by Dr. Robert B. .Armstrong, Ida
Grove, and Dr. H. R. Pascoe, Carroll.
Some Surgical Conditions the General Practitioner
Meets — Dr. E. C. lunger. Soldier.
Management of Minor Surgery, or Minor Surgery
in General Practice — Dr. Paul W. Van Metre, Rock-
well City. Discussion on the last two named papers
opened by Dr. E. E. Speaker, Lake View, Dr. J. J.
Meehan, Denison, and Dr. James McAllister, Ode-
bolt.
The Criminal — Dr. Lena A. Beach, Rockwell City.
Discussion opened by Dr. C. C. Bowie, Carroll, and
Dr. A. C. Norton, Rockwell City.
.A_ Series of Prostatectomies, with Exhibition of
Specimens — Dr. E. S. Parker, Ida Grove. Discussion
opened by Dr. O. C. Morrison, Carroll, Dr. M. J.
McVay, Lake City, and Dr. Carlisle, Manning.
Diagnosis of Diseases of the External Eye — Dr.
J. S. Buzard, Carroll. Discussion opened by Dr. J. H
Stalford, Sac City, Dr. I^. M. Coon, Denison, and Dr.
G. W. .Anderson, Early.
Evening Session, 7:30 p. m. — Five thousand feet
of motion picture film from actual photography in
the Wertheim Obstetrical Clinics, covering topics as
follows: Clinical Examination for Pregnancy; .Ab-
normalities of the Female Skeleton; Normal De-
livery; Breech Presentation; Face Presentation and
Delivery; Resuscitation of a Child; Walcher Posture;
Eclampsia; Breech Presentation with E.xtraction of
Child; Podalic Version from Head Presentation and
Extraction of Child by the Foot; Extraction of Dead
Foetus by Foot with Perforation of the After Com-
ing Head; Craniotomy; Forceps Delivery; Caesarian
VoL. XII, No. 81
Journal of Iowa State Medical Society
347
Section; Caesarian Section with Hydrainnios; Exam-
ination of Prolapse of Uterus; Removal of Ovarian
Cyst by Abdominal Sections.
Address — The Lost Art of Obstetrics, Dr. Palmer
Findley, Omaha.
Officers — President, Dr. J. H. Stalford, Sac City;
vice-president. Dr. H. L. Fobes, Auburn; secretary,
Dr. L. H. Jones, Wall Lake; treasurer, Dr. G. C.
Moorehead, Ida Grove.
Medical Women’s International Association
The second meeting of the Medical Women’s In-
ternational Association will be held at Geneva, Swit-
zerland, from the fourth to the seventh of September
nineteen twenty-two. All members are urged to be
present. Each society of medical women in the
world is invited to send one eligible delegate and an
additional delegate for every hundred members.
Interesting reports will be read by medical women
from different countries and the constitution of the
organization will probably be revised in accordance
with the provisions under which it was adopted.
Clinics in the different European countries may be
visited enroute. The attractions of travel in Europe
are great this year. Practically all countries are ac-
cessible and the passion play will be on at Oberam-
mergau during the entire summer.
PERSONAL MENTION
Dr. L. M. Munson of Chicago, has associated him-
self with the Fort Dodge Clinic on the eighth floor
of the Carver building. He is a graduate of the
University of Chicago and Rush Medical College of
the class of 1910, and after that spent three and a half
years doing post-graduate work in the Presbyterian,
St. Lukes and Alexian Bros., hospitals in Chicago.
Dr. Munson will be consulting medical and surgical
advisor to the clinic and specialize in internal med-
icine and diagnoses. Also he will supervise the clin-
ical laboratory, with Mr. R. S. Hopkins, of Chicago,
as technician.
Dr. J. E. King, Eldora, had a very happy day June
9 when he received the congratulations of many
friends on his having reached the ninety-seventh- an-
niversary of his birth. The doctor was feeling re-
markably well, and the members of his family joined
with him in an old time family dinner at the home
of his son, O. J. King. He took great delight in
cutting his own birthday cake. His son. Jay A. King
of Des Moines, and grandson Harry Brookins and
Wife, of St. Paul, were present on that occasion.
Dr. Walter Bierring has left for a six weeks’ trip
abroad. Dr. Bierring will spend the greater part of
his time in Scotland. While at Edinburgh he will
have a high degree conferred upon him by Edinburgh
University in recognition for medical services of un-
usual character during the World War.
Dr. W. L. Donnelly, who has just returned from
Johns Hopkins University at Baltimore, Maryland,
will open an office at No. 614 Kahl building, Daven-
port. Dr. Donnelly is a specialist in urology and will
limit his practice to that particular field. He was
associated with Dr. Hugh H. Young in the Brady
Urological Institute at Johns Hopkins and has had
wide e.xperience in his line of work. Dr. Donnelly
was formerly of Clinton, Iowa.
Dr. las. K. Biddle has arrived to take up his work
as surgeon at the Carroll Clinic. He is a native of
Ohio, received his literary training at Ohio Univer-
sity and his medical training at Baltimore. In the
years 1909 and 1910 he was resident surgeon at the
Baltimore City Hospital. For the past five years he
has been doing general surgery in the Pittsburg dis-
trict. He is a graduate of the Army Medical School
at Langres, France, and also studied in Paris and
London. Dr. Biddle was in army service two years
and holds the rank of major. After the armistice
was signed, he was with the army of occupation and
spent six months at Coblenz on the Rhine.
Dr. Arthur Steindler, professor of orthopedic sur-
gery at Iowa University, and head surgeon at the
Children’s Hospital across the river has left for the
East. He will sail for Europe and pass the coming
three months at his old home in Vienna, Austria.
Dr. J. T. Priestley of Des Moines, whose knee was
injured several weeks ago when he was struck by an
automobile, is able to be at his office every day.
Dr. Grover of Halbur moved to Manning about
the first of June and opened an office in the rooms
over the Reinholdt Hardware Store, formerly occu-
pied by Dr. Sievers.
Dr. Frank E. A. Thone, 1609 Edison avenue, son
of Mr. and Mrs. Charles Thone, will go to Yellow-
stone National Park where he will lecture this sum-
mer to tourists, explaining rock formations in the
park and other things of interest. Dr. Thone will
be employed by the government. He received his
degree of doctor of philosophy at the University of
Chicago on May 22, 1922.
The Fort Madison Medical Society honored Dr.
Max A. Schlapp, former Fort Madison man and
famous New York neurologist by entertaining him
at a 6 o’clock dinner at the Iowa cafe May 24. All
members of the Fort Madison Medical Society were
present. Dr. Schlapp addressed the meeting, speak-
ing upon his work and the plans for a pathological
laboratory for Fort Madison.
Dr. B. L. Eiker of Leon departed recently for St.
Louis where he is attending the meeting of the
American Medical Association in session there this
week. Dr. Eiker is one of three delegates sent from
the Iowa State Medical Association to the national
meeting.
Phillip and Dr. Lucy Busenbach Harbach, formerly
of Des Moines, who went to Germany to live fol-
lowing the World War, will return to Des Moines
shortly to take up residence there. The Harbachs
are dissatisfied with conditions in Germany it is re-
ported.
Dr. C. E. Broderick, who has been taking advanced
work in a hospital at Washington, D. C., has ac-
cepted an offer to act as ship doctor on a ship owned
348
Journal of Iowa State Medical Society
[August, 1922
by the White Line Steamship Company, during the
illness of the regular ship physician. He is sailing
for South America, Jamaica, Panama and numerous
southern points.
Ur. T. K. Campbell of Rolf has purchased the
equipment of the late Dr. E. E. Smith and will re-
move to Sioux Rapids.
Dr. Z. R. ,\schenbrenner has located in Pella. Dr.
Aschenbrenner is a graduate from the medical de-
partment of the Iowa State University and served
as an interne at Harper Hospital, Detroit, two years.
Dr. L. E. Jensen has decided to locate permanently
at Audubon. He will take an office with Dr. A. L.
Brooks with whom he will be associated in the prac-
tice of medicine.
Dr. Jackson formerly of Spirit Lake has located
at Arcadia to practice medicine.
Dr. George S. Waterhouse, a graduate of the class
1895 in medicine at Iowa State University, now lo
cated at Mapleton, has been seriously ill but is now
said to be recovering his health.
HOSPITAL NOTES
Ur. Raymond Clare Coleman has awarded a con-
tract for a splendid new hospital, at Estherville. It
will cos.t about $60,000.
The general contract for the new’ addition to Sun-
nyslope Sanitarium, Ottumwa, was let by the board
of trustees of the institution, of which E. P. Barton
is treasurer, to the Ottumwa Mill and Construction
Company. The local firm’s figure was $24,312.
Dr. J. L. Smith of Chicago, chief inspector of hos-
pital under the auspices of the College of Surgeons,
made a complete survey of St. Anthony Hospital,
Carroll, and found everything very satisfactory. The
lecords were pronounced correct, and he compli-
mented the sisters and gave much credit to them for
their work. This is the annual inspection and is
made in connection with the standardization of
hospitals.
Miss Margaret Paulus of Mason City has assumed
charge of the Eldora Hospital.
Fifteen thousand dollars’ worth of radium be-
longing to Dr. I. I. Flannery, 4215 Grand avenue, was
lost at Mercy Hospital, it was revealed June 14 and
the traditional search for the needle in the haystack
was enacted with grim seriousness.
Beginning June 1, Drs. M. L. and L. E. Hooper
took over the management of Bethel Hospital in
Indianola. The ownership of the hospital will re-
main in Dr. Newsome, only the management passing
to the Drs. Hooper.
It will be maintained as in the past as a general
hospital open to all reputable physicians in the
county. Miss Isabel Willett, a graduate nurse well
known in Indianola for a number of critical cases
she has successfully nursed, will be the superintend-
ent in charge.
OBITUARY
Dr. G. O. Blech died at the family residence, 1048
Central avenue, Dubuque, June 6, after an illness of
two months’ duration.
He was born February 27, 1852, in Brandejburg,
Germany, and was educated and graduated from the
college at Sorau, Germany. He later studied medi-
cine and was graduated from the University of
Marburg. Twenty-eight years ago he came to Dav-
enport, making his home in Davenport until fifteen
years ago when he moved to Dubuque, where he had
since resided. He was a member of the Dubuque
Medical Society, St. John’s Lutheran Church and of
the Saengerbund.
Ur. John Frederick Baker of Davenport, aged
seventy-seven years, died June 15 at 9:30 o’clock at
his home, 1420 Iowa street. He had been in ill
health for several years following an operation.
Dr. Baker, who was one of the fourth generation
of a family of doctors, was born in Meriden, N. H.,
on September 14, 1845, coming to Davenport with his
parents in 1845. His father, Dr. J. W. H. Baker, was
a well know’n physician. He was educated in the
schools here and at Griswold College then located
in Davenport. He also took work at Cable Union
Academy at his old home town, Meriden, becom-
ing associated with his father on his return from
school. After spending some time at Ballard’s drug
store, he continued his medical studies at Bellevue
Medical College in New York City.
Following his graduation he assisted his father
for a time and then moved to St. Paul, Minnesota,
where he practiced for twenty-five years. He and his
family returned to Davenport in 1910. He was a
member of the Presbyterian Church.
Dr. Baker was married to Miss Sarah L. Merrill
at Madison, Wisconsin, on July 26, 1871. She sur-
vives with one son, John F., Jr. Other surviving rel-
atives are Dr. C. R. Baker of Davenport, Dr. O. F
Baker of Shell Lake, Wisconsin, and two sisters,
Mrs. F. A. Crouch and Mrs. J. R. Smith of Daven-
port.
Dr. E. E. Smith, a practicing physician in Sioux
Rapids for the past twenty-four years, died suddenly
of heart disease April 20. Dr. Smith was born at
Waterloo on September 30, 1873.
After completing the high school he entered Iowa
State College, .^mes, and graduated in the class of
1893. He then entered the Medical College at Cin-
cinnati, Ohio, and graduated in 1898. On May 10,
1900, he married Georgia Adah Bashford of Cin-
VoL. XII, No. 8 1
Journal of Iowa State Medical Society
349
cinnati to whom were born tliree children who sur-
vive him.
Dr. Smith was a competent, popular and successful
physician, was active in local affairs and occupied
many responsible positions of trust.
THIRTY-FIFTH ANNUAL MEETING OF THE
MEDICAL SOCIETY OF THE MISSOURI
VALLEY
The Thirty-fifth annual meeting of the Medical
Society of the Missouri Valley will be held at St.
Joseph, under the presidency of Dr. Paul E. Gardner,
September 21 and 22.
series of clinics will be held at the various St.
Joseph hospitals September 19 and 20. .-\n e.xcellenl
.scientific program will be presented including a Sym-
posium “The Early Recognition of Cancer." Other
papers will be given by Dr. C. W. Hopkins, Chief
Surgeon C. & N. \V. Ry.; Dr. N. M. Keith, of the
Mayo Clinic; Dr. I. H. Dowd, Buffalo, X. V., and
others.
Headquarters and meeting place at the Robidoux
Hotel. Please make your reservations early. .Ad-
dress Dr. Chas. Woods Fassett, Kansas City, Mis-
souri, for complete program.
BOOK REVIEWS
C L I X 1 C A L TU B E R CU LO S 1 S
By Francis Marion Pottinger, .\.M., M.D.,
LL.D., Medical Director, Pottinger Sana-
torium, For Diseases of the Lungs and
Throat, Monrovia, California. With a chap-
ter on Laboratory Methods. By Joseph El-
bert Pottinger, M.D., .Assistant Medi-
cal Director and Director of the Laboratory
Pottinger Sanatorium. In two volumes.
Volume One, Pathological .Anatomy, Patho-
logical Physiology, Diagnosis and Progno-
sis. Second Edition with lO.s Text Illustra-
tions and Charts and 6 Plates in Colors. \'ol-
ume Two, Complications and Treatment with
6.^ Te.xt Illustrations and Charts and 4 Plates
in Color. C. Mosby Company, St. Louis,
1922.
'Phis voluminous work presents an e.xhaustive ac-
count of our knowledge of tuberculosis in all its
medical relations by men who have devoted many
years of study to the subject with a vast amount of
material at hand and under the most favorable cir-
cumstances. The study of tuberculosis has been con-
ducted in a private sanatorium in patients of un-
usual intelligence, who could cooperate with the
physician to an unusual degree in following methods
of study and treatment. In the large number of pa-
tients who come under the care and direction of Dr.
Pottinger, there were representatives of all stages
of the disease; from the incipient forms to all stages
of development, thus giving an opportunity for the
most complete clinical study of the disease.
Chapter one lays the foundation for the clinical
study of tuberculosis, and chapter two the sources
and routes of infection. Chajtter three the relation-
ship of the primary focus to clinical tuberculosis.
In chapter four we find the important subject of tu-
berculosis in childhood, and so we pass on to chapter
twelve to the consideration of trauma as a factor in
producing tuberculosis. 4'his has been a subject of
much medico-legal interest. Dr. Pottinger very cor-
rectly shows, as we believe, that with our present
knowledge of the essential causative factors in tu-
berculosis, that when infection has occurred, that
an implantation may be favored by a traumatic con-
dition, and further, a quescent focus, in a way to mo-
bilize bacilli by a trauma. The question is fully dis-
cussed as relates to a particular case. Several chap-
ters are devoted to the diagnosis of tuberculosis by
physical examination, tests, x-ray and by laboratory
methods, their value and the elements of error. It
is made quite clear in the first volume that an early
diagnosis of tuberculosis involves great care and an
exhaustive study of the patient. So important is an
early diagnosis that a conscientious physician owes
it as a duty to his patient and to himself to read
and study this volume with great care. Dr. Pottinger
is not dogmatic but presents the evidence to the
serious consideration of the reader.
The second volume is largely devoted to the treat-
ments of tuberculosis. Of course, it follows, that the
treatment is based on a rational consideration of the
evidence presented in the first volume. To base a
treatment on an assumption of tuberculosis without
taking into consideration the pathology and the pos-
sible complications so thoroughly set forth in volume
one, is unscientific, and will lead to disappointment,
and injustice to the patient. These two large vol-
umes may seem something of an undertaking but it
is really worth while, and we feel that when one hat
once entered earnestly on the task, he will find his
interest increasing.
AMERICAX ll.LL'STR.KTED MEDICAL DIC-
TIONARY (DORLAXD)
.■\ Xew and Complete Dictionary of Tertiis
L’sed in Medicine, Surgery, Dentistry, Phar-
macy, Chemistry, Veteniary Science, Nurs-
ing, Biology, and Kindred Branches, with
New and Elaborate Tables. Eleventh Edi-
tion; Revised and Enlarged; Edited by W. A.
Newman Dorland, M.D.; Large Octavo of
1229 Pages with 338 Illustrations; 141 in
Colors, Containing 0%'er LsOO New Terms.
\V. B. Saunders Company, 1921. Price Flex-
ible Leather $7.00 Net; Thumb Index $8.00
Net.
'I'he medical profession is again under obligations
to W. B. Saunders Company for in a little more
350
Journal of Iowa State Medical Society
[August, 1922
than a year, to issue a new anil enlarged edition of
Dorland's Medical Dictionary.
rite wide range which this dictionary covers ren-
ders it an indispensible adjunct to every professional
library even including the library of an attorney.
The addition of thirty pages and 1300 new terms
“^hows that while the previous edition is of great
;,lue, the new edition becomes a necessity. It
further shows the increasing but wider range of med-
ial and allied science in relation to the profession
itself and to the public.
BOOK OX THE PHY.SICIAX HIMSELF, FROM
GRADUATION TO OLD AGE
By D. \\. Cathell, M.D. This is the vastly
improved crowning edition. Published by
tbe author, Emerson Hotel, Baltimore, Mary-
land.
In these days of restlessness on the part of the
medical profession the inquiry constantly arises what
can we do to reach success? One says, that we are
confronted by unfriendly or threatened unfriendly
legislation; author says that it is free clinics, auto-
cratic medical organizations, or other influences be-
yond ourselves that are at fault. Let us read what
Dr. Cathill says. It was many years ago that we
had the pleasure and advantages of reading an earlier
edition of “The Physician Himself” in which Dr.
Cathill pointed out the personal attributes of the
physician which led to success or to partial failure.
Dr. Cathell has now reached the mature age of
eighty-three years with fifty-seven years practice to
his credit. During this time remarkable changes
have occurred in the practice of medicine. The vast
changes which have taken place in the science and
art of medicine and its various branches has greatly
increased the responsibility of the physician, but
his moral and social obligations are the same. His
duties to his patients and to the public are essen-
tially the same, according to his newly acquired
knowledge.
T'he fundamental proposition relates to two prin-
ciples, "A greater scientific side and a lesser but
very important personal side.” Dr. Cathell lays great
stress on the need of the physician placing the in-
creased and increasing knowledge oi the science of
medicine at the service of his patient and the public
in the true scientific spirit and gives great praise to
thqsc who have generously made possible the ad-
vancement of knowledge, and particularly refers to
the Rockefeller Foundation. The importance of the
personal side is a long story and relates to our con-
duct towards our professional associates and the pa-
tience and courtesy towards the general public which
may be included under the general term of being a
gentleman in the highest sense of the word.
When we attribute our failure to succeed to the
fault of others and lose sight of our own short-
comings let us read what Dr. Cathell says in a prayer-
ful state of mind and perhaps a new light may come
to us. This is a book that the young practitioner
should read before fixed ideas are formed, and it
may not be too late for the older men to study with
some hope for the future.
THE MEDICAL CLINICS OF NORTH
AMERICA
(Issued Serially, One Number Every Other
^lonth.) \’olume Five, Number Four. Jan-
uary, 1922. By New York Internist. Oc-
tavo of 214 Pages with 35 Illustrations. Per
Clinic \ ear (July, 1921 to May, 1922). Paper
$12.00 Net; Cloth $16.00 Net. W. B. Saun-
ders Company.
A few contributions will illustrate the character
of this New York number. The first clinic number
IS by Dr. Warfield T. Longcope, “Epidemic Jaundice
with Special Reference to ^ilild Forms Occurring in
the United States.” At Bellevue Hospital "The
TTeatment of Pneumonia,” by Dr. Harlow Brooks.
“Five Common Clinical Types of Appendicitis,” Dr.
John L. Kantor, \'anderbilt Clinic, at the Harlem
Hospital. A case of “Hypernephroma with Spinal
Metastases,” by Jesse G. ^1. Bullowa.
These papers furnish fair examples of the eleven
clinical papers presented in this number.
HAY FEVER •
The desensitization treatment of hay fever patients
is now in full swing, for the annual August datings
have not been canceled. However, there are pro-
crastinators and unbelievers in this domain of ex-
periment, as in all others. There will be plenty of
hay fever this year, notwithstanding the endorsement
of the pollen extract desensitization treatment (pro-
phylactic) by Dr. Scheppegrell, president of the
.'\mcrican .Association for the Prevention of Hay
Fever (who has just written a book on the subject),
and others. These patients are not altogether at the
mere}' of the ragweed, however, for it is possible to
mitigate their condition by the application of oint-
ments, inhalants or sprays.
The nasal mucosa is disorganized, relaxed, weep-
ing, as a result of the pollen bombardment. It can
be toned up to a material degree of resistance and
independence by the use of adrenalin (P. D. & Co.)
in spray, inhalant or ointment form. When a com-
paratively weak solution is used in spraying, no re-
action follows, and the applications may be repeated
as often as desired without risk of toxic effect. Oint-
ments and inhalants of adrenalin are rather more
convenient to use than the spray, though not so
prompt in their effect. They con, tain adrenalin
1:1000, and it is the gradual release of the adrenalin
that prevents a too pronounced astringent effect
when they are applied.
Jfoumal of tf)e
Jlotoa ^tate Jiletiual ^cietp
VoL. XII Des Moines, Iowa, September 15, 1922 No. 9
OUR PRESENT KNOWLEDGE AND EXPE-
RIENCE CONCERNING CESAREAN
SECTION*
Edward P. Davis, M.D., Philadelphia
There has been time for the early enthusiasm
concerning Caesarean section to abate ; for the re-
sults (good and bad) of the operation to become
apparent ; for a check to be put upon the im-
proper performance of the operation and more
accurate knowledge obtained concerning this im-
f>ortant procedure.
A highly contracted pelvis in a woman ad-
vanced more than a few months in pregnancy is
today a self-evident indication for Caesarean sec-
tion. A central placenta praevia in a primipara
considerably beyond the average age of child-
bearing, with child at or near term and in good
condition, the cervix unsoftened, unshortened and
undilated is, from the standpoint of surgery, a
self-evident indication for delivery by section. A
normally implanted placenta undergoing prema-
ture separation in a patient with undilated and un-
dilatable birth canal comes under the same cate-
gory; but while these are simple problems there
are other conditions where the choice of opera-
tion requires especial training and experience.
Border line pelves furnish a difficult problem.
We are yet without an absolutely accurate method
of measuring the size of the foetus. Frequent ob-
servation during pregnancy in primiparae to de-
termine the presence or absence of descent and
engagement is our safest guide. So soon as the
natural phenomena of the last weeks of preg-
nancy in a primipara do not develop, the question
of interference or abstinence from interference
must be seriously considered. This is true in
some other conditions than contracted pelvis.
Where the uterus is deficient in development and
the child well developed descent and engagement
may fail. Abnormal presentation and position
complicate such a situation.
In multiparae the history of a previous labor is
valuable evidence. The progressive increase in
*Address Presented at the Seventy-First Annual Session, Iowa
State Medical Society, Des Moines. Iowa. May 10, 11, 12, 1922.
the size of children under favorable conditions is
an element of importance. The mental attitude
of the patient, her desire for a child, her age and
other circumstances must all be considered. In-
duced labor does not properly compete with
Caesarean section, as both are intended to save the
life of the child.
In multiparous patients who have had difficult
and dangerous labors and who are brought to the
attention of the obstetrician after efforts have
been made to deliver the child, the choice of a
method of procedure is sometimes difficult. Un-
less there is reason to believe that the patient has
been in reasonably clean hands and that the child
has a good chance for life. Caesarean section
should be declined for embryotomy. Enthusiasm
in the performance of the operation has led to its
improper performance in some of these cases.
In multiparae who have a number of children
living who can be supported with difficulty and
where the mother shows the strain of repeated
parturition, the question of birth control comes up
in a very important and practical manner. With
the consent of husband and wife, if the patient is
seen before labor, elective Caesarean section with-
out labor may be chosen, followed by steriliza-
tion. If the patient is over forty, the best results
in the experience of the writer, are obtained by
the removal of the tubes and ovaries with supra-
vaginal hysterectomy. This leaves the patient in
the best condition for comfortable health, and if
lactation can be established, the disagreeable
symptoms of the menopause often become insig-
nificant. This class of cases are especially com-
mended to the attention of the profession, for
these women should be freed from the burden of
further child-bearing and also from the dangers
of ovarian and uterine diseases which often de-
velop in later life. If the cervix is in good condi-
tion it is reasonably safe to perform supravaginal
hysterectomy instead of extirpation of the uterus.
If there is reason to suspect the condition of the
cervix, then extirpation is indicated.
In primiparous patients every effort shovild be
made to continue the power of reproduction. If
the patient is infected by repeated examinations
352
Journal . OF Iowa State Medical Society
and efforts to deliver, if the condition of the
uterus is good and the patient has not had severe
hemorrhage, an effort should be made to forestall
infection by thoroughh- cleansing the uterine cav-
ity with sterile gauze and packing the uterus with
10 per cent iodoform gauze. Saprsemia will often
develoj) in these cases, but if the uterus be kept
tightly contracted the patient will recover without
serious infection.
Three methods of operating are available, the
classic section in which the uterus is turned out
of the abdominal cavity through an anterior inci-
sion, closed and replaced ; the so-called high oper-
ation where the abdomen is opened at or above
the umbilicus, the uterus remaining in the abdo-
men, emptied of its contents and then closed ; and
the method of incision through the lower uterine
segment. While the last was originally sup-
]K)sed to be extraperitoneal, experience shows that
this is rarely possible. Some attempt to forestall
infection by stitching together the abdominal and
uterine peritoneum before opening the uterus, thus
operating through a uterine and abdominal fistula.
Monroe Kerr makes a transverse incision through
the lower segment and Beck makes a two flap
operation, attempting to protect the abdomen from
infection by the double flap sutured over the line
of incision.
The merits of the classic section and section by
high incision are well established. Incision
through the lower segment gives promise of good
results but sufficient experience has not accumu-
lated to give accurate data. In all three varieties
the essential of successful operation consists in
accurately closing the muscular tissue of the
uterus. W'hen this has been done this line of
suture should be accurately protected by uniting
the peritoneum over the first line of stitches. To
avoid infection some operators push the placenta,
membranes and cord through the cervix into the
vagina, whence they are removed in the usual
manner. few English operators turn the
uterus inside out before suture to avoid hemor-
rhage and to comjdetely remove the membranes
and as much of the decidua as ])Ossible by rub-
bing the inner surface of the uterus with sterile
gauze.
The avoidance of hemorrhage during and after
Cje'^arean section depends upon accurate closure
and u])on the prompt contraction of the uterus.
This can usually be obtained bv gentle massage,
by closing the uterus when retraction is well de-
veloped and by giving hypodermically, stimuli to
promote uterine contraction. Some operators in-
ject pituitrin into the uterine muscle as the uterus
[September, 1922
is closed, others rely upon hypodermic injections
of strychnia and ergot.
The intrauterine packing of iodoform gauze is
efficient stimulus to uterine contractions and
aids greatly in the prevention of hemorrhage.
It is recognized that Caesarean section which
is not followed by hysterectomy, leaves the pa-
tient with a uterus which may rupture in subse-
quent pregnancy or labor. A very careful survey
was recently made of Caesarean section in Great
Britain. A recent number of the Journal of Ob-
stetrics of the British Empire is devoted to the
subject of Caesarean section. Holland’s careful
study shows that in general the woman who has
had a Caesarean section has a risk of rupture of
the uterine scar in subsequent pregnancy and
labor of 4 per cent. This risk can be reduced ven,-
materially by employing a suture material in the
uterine muscle whose knots are not easily loosened
and which is absorbed very gradually or not at
all. The ideal material for these sutures would
be flexible silk work gut and next in value, the
best quality of surgical silk and least safe, cat
gut. Experience shows that cases in which infec-
tion occurs after operation, are usually liable to a
bad uterine scar. Microscopic study of these
uteri when removed subsequently, shows that the
normal muscular tissue of the uterus is replaced
by fibrous and connective tissue, this becomes
thinned by the increasing pressure of pregnancy
and is especially liable to rupture in pregnancy
and labor.
An element of confusion has arisen in this mat-
ter from the fact that in certain cases of women
in bad general health, who have repeatedly
borne children, the uterus undergoes degenerative
processes which predispose to rupture, and when
rupture occurs in these cases, it is frequently not
through the uterine scar, for the uterine scar may
be the strongest part of the uterus, hence it is un-
fair to charge the operation with rupture in these
patients.
An interesting point arises as to the general
result of Ctesarean section as now practiced. Re-
cent statistics show that clean cases operated upon
by elective section, have a maternal mortality of
considerably less than 2 per cent ; each vaginal
examination increases the mother’s risk and so
does each hour of labor with ruptured mem-
branes. The most important factor in the mor-
tality after Caesarean section is unsuccessful ef-
fort to deliver preceding the operation. In cases
of section done upon patients in whom an effort
had been made unsuccessfully to deliver by for-
ceps, the maternal mortality ri.ses to more than
25 per cent. No more striking argument can be
VoL. XII, No. 9]
Journal of Iowa State Medical Society
353
adduced to the necessity of accurate diagnosis be-
fore the use of forceps is attempted.
A safe rule to apply in deciding upon the oper-
ation is to remember that the uterus of each par-
turient woman, no matter how carefully her labor
is conducted and though that labor may be spon-
taneous, is practically infected in the few days
following labor. This is shown by recent bac-
teriological studies which demonstrated the fact
that bacteria from the vagina and cervix, strep-
tococci and others, are present in the uterine
cavity by the fifth day after labor. The fact that
all women do not become infected is explained
by the immunizing bodies in the blood of the
mother, the tight plugging of uterine sinuses by
aseptic thrombi, and efficient contraction of the
uterine muscle. Aside from direct implantation
of bacteria, hemorrhage most certainly predis-
poses to infection. Patients who have had hemor-
rhage during labor and on whom unsuccessful at-
tempts have been made to deliver, are bad risks
for Caesarean section.
While this is true, desperate cases can be saved
by hysterectomy provided the stump be left out-
side the peritoneal cavity. In the writer’s expe-
rience a primipara during three days and nights
of labor was subjected to attempted delivery by
forceps, version and craniotomy, all of which
were under anesthesia, considerable hemorrhage
accompanied each attempt. She was then placed
upon a cot in a railway car and brought eighteen
miles to the hospital. On admission it was stated
to her husband and sister that sacrifice of the
uterus was the only remaining hope. On opening
the uterus the interior was so foul in odor that
one of the nurses present fainted. The wall of
the uterus and its decidua were greenish in color.
The Porro operation was performed with use of
the clamp, the stump outside the abdominal cav-
ity. This patient made a complete recovery.
It is worse than useless to perform Caesarean
section upon an infected patient and drop the
stump after hysterectomy. Septic infection is
practically sure to follow. In patients who re-
cover from this Porro operation the condition of
the pelvic region is excellent. The stump of the
cervix is held firmly high at the pelvic brim, pro-
lapse is impossible and the general health of the
patient is good. In badly nourished women
hernia occasionally develops but this is reme-
died by subsequent operation a year or two after-
ward. Hernia after the classic Caesarean section
or that by high incision or by incision through the
lower segment is comparatively rare.
Adhesions are one of the most unfortunate
after results of abdominal surgery. After Caes-
arean section, adhesions between the anterior ab-
dominal and uterine walls are not infrequent. Pa-
tients rarely complain of inconvenience after re-
covery but in subsequent pregnancy there may be
pain caused by traction upon these adhesions as
the uterus grows. In repeated 'Caesarean section
adhesions must be dealt with in accordance with
their situation and extent. In the experience oi
the writer they have never been formidable. The
presence of these adhesions was formerly thought
to be a safeguard against peritonitis.
Where infection develops after Caesarean sec-
tion if usually arises from the interior of the
uterus. Bacteria make their way along stitches
in the uterine muscle, thence to the peritoneal
covering and if adhesions are present they next
attack the catgut which closes the peritoneum,
following the same line through the fascia. An
infected stitch hole abscess may cause an ab-
dominal and uterine fistula. This may save the
patient from a general peritonitis and the writer’s
never seen one of these fistulas which did not sub-
sequently close.
In general what is urgently needed is a thorough
knowledge of the presentation and position of the
fetus and the size of the mother’s pelvis. In the
first stage of labor the diagnosis of engagement,
moulding and descent is of primary importance.
The application of forceps to a floating head is
the worst possible practice. Version without pel-
vimetry is equally bad. Unless the natural phe-
nomena of descent and engagement develop in the
last days of a first pregnancy, complications must
be expected. Palpation and auscultation should
prevent useless vaginal examinations. Examin-
ations through the rectum the writer has not prac-
ticed. The choice of Caesarean section should be
made early in the progress of the labor and not as
a last resort.
The second point of great importance is the
general condition of the patient from which a fair
inference may be drawn concerning the state of
the uterine muscle. In ill developed primiparas
the uterus may be so thin and lacking in force
that vaginal delivery at term may be more dan-
gerous than section. In all pregnant patients who
are highly toxic the uterine muscle is dangerously
injured by the toxemia. In multiparae who so
often have fibroids and fatty changes in the uter-
ine .muscle, the danger of uterine rupture during
labor must not be forgotten.
Caesarean section is often indicated to save not
only the life of the mother but the life of the
child. The general mortality of infants born after
Caesarean section is approximately 3 per cent.
This does not often arise from the operation itself
354
Journal of Iowa State Medical Society
[September, 1922
but from the conditions which indicate the oper-
ation. Birth pressure in long continued labor, fol-
lowed by asphyxia and cerebral hemorrhage, is
one of the most frequent causes of fetal death.
It is useless to subject the mother to the risk of
radical operation if she be so toxic that her fetus
will die shortly after labor from toxemia. Some
of the most excellent results seen from section
are in placenta previa when the mother has had
but one sharp hemorrhage and prompt operation
delivers a vigorous child and saves the mother.
In accidental separation of a normally implanted
placenta the child is always exposed to risk of
asphyxia from intra-uterine bleeding.
A difficult decision at times is the choice be-
tween leaving and removing the uterus. The
haemolytic property of the blood of the pregnant
woman may occasion a condition of the uterine
muscle known as necrobiosis accurately described
by Couvelaire and others. The uterine muscle
at operation is found dark currant jelly color,
much softer than normal and of such consistency
that stitches will not safely hold. This is es-
pecially well developed at the placental site. In
these cases hysterectomy may become imperative.
Who shall perform Caesarean section? The
technical performance of the operation is rarely
difficult, but a thorough knowledge of obstetric
diagnosis and experience with purturient women
are necessary for a wise decision to operate.
The general practitioner has been called by
some the great obstetric specialist. The fact that
there has been no recent improvement in the mor-
tality and morbidity of parturition in private
houses does not indicate his especial success. The
reason for this state of affairs lies in the fact that
labor, spontaneous or otherwise, is a surgical pro-
cedure to be conducted with surgical cleanliness
in all cases.
The general practitioner has the most interest-
ing and important specialty in medicine, that of
diagnosis. The fate of a parturient patient often
lies in the hands of the man or woman w'ho first
sees her. \Vith improved roads, motor cars and
many hospitals, it is rarely impossible when a
diagnosis is made that operation is necessary, to
convey a patient to a hospital where an obstetri-
cian cannot be summoned to deliver her.
In general, it may be said without exaggera-
tion, that delivery by abdominal incision has
robbed contracted pelvis of its terrors for mother
and child. It has greatly lessened the mortality
and morbidity of disproportion between mother
and child provided previous attempts at delivery
have not been made. It has greatly lessened the
mortality and morbidity of the more dangerous
varieties of placenta prievia. It is occasionally
useful in eclampsia, prolapse of the cord,
shoulder presentation and abnormalities in the
structure of the uterus.
With your kind permission I will show slides
of uteri removed from patients who previously
had Caesarean section performed by the classic
method. In all of these the uterine muscle was
closed by silk, the peritoneum of the uterus, of
the abdomen and the fascia by cat gut. The ab-
dominal skin by silk worm gut. In many of these
cases packing was used, in others it was not.
Some of these uteri ruptured in subsequent la-
bors and one uterus was removed by elective sec-
tion from a woman in a highly toxic condition.
THE HUMAN BREAST, A PLEA FOR
WELL DIRECTED TREATMENT
BASED ON MORE ACCURATE
DIAGNOSIS*
William Seaman Bainbridge, Commander,
M.C., U. S. N. R. F., New York City
One of the great advances today in the profes-
sion of medicine is the changing attitude concern-
ing health and disease. Gradually, the emphasis
is being placed upon health maintenance rather
than upon the cure of disease. Co-incident with
this comes a nation-wide campaign along health
lines, the hygienists advocating examination at
definite intervals for the early detection, recogni-
tion and treatment of disease.
In the industrial and mercantile world the value
of good health, from an economic standpoint, is
being recognized, and there is a tendency to apply
the efficiency expert in medicine, surgery and
sanitation, as well as in various business and in-
dustrial pursuits. Many insurance companies,
merely as a matter of business, are retaining corps
of physicians and nurses to help prevent serious
illness and possible fatality by the early detection
of disease. The United States Bureau of Mines
is constantly making experiments in an effort to
lower sickness and mortality rates among miners,
factory workers, and laborers of all classes. Na-
tional, state and local boards of health are repeat-
edly stressing the importance of preventive
measures. In special fields the American Asso-
ciation of Cancer Prophylaxis is one of the many
organizations doing very useful service. Other
agencies are emphasizing these points, but the
examples quoted are sufficient to prove the trend
of our times.
*R^ad before the Tri-State Medical Society, Waterloo, Iowa,
October 4, 6, 6, 7, 1920.
VoL. XII, No. 9]
Journal of Iowa State Medical Society
355
Thus, from these many sources, the public is
urged to consult the physician at any deviation
from the normal — in fact, it is asked to come
from time to time, even though there is no evi-
dence of disease. It is recognizing the force of
these arguments and is slowly responding. The
patients who come justly demand a recognition of
all the aspects of the individual case.
The medical profession must be keenly alive to
the importance of developing its ability to diag-
nose cases in their early stages. At times it has
the unfortunate attitude of underestimating minor
conditions and mentality pronouncing the symp-
toms merely those of hysteria. Physicians should
not be so engrossed with acute illnesses, acute
conditions, and more advanced pathology, as to
fail to realize the importance of a thorough exam-
ination of all patients who seek medical care and
attention, no matter how trivial the complaint
may be for which they come. Early detection
of an almost hidden danger signal may result in
sparing the patient much future mental and phy-
sical suffering.
There is always the danger of overestimating,
as well as under-estimating, pathological condi-
tions. Many can remember the period of the
massacre of the ovaries, later of the appendix,
then of the tonsils and colon, and more recently
of the teeth. Is it possible that in the attempt to
prevent cancer there may be the risk of another
period of unnecessary sacrifice — that of the
human breast? By way of illustration, there is
the patient who discovers a lump in her breast
and delays her visit to the physician by visioning
mentally over his door, a sign which reads,
“Abandon hope of escaping a terrible operation,
all ye who enter here.” On examination the phy-
sician may fail to weigh in the balance all the
non-malignant possibilities involved, and permit
her to leave his office with the belief that opera-
tion is the only means of saving her life. Ac-
cepting this verdict, the patient may be subjected
to an unnecessary mutilating operation for a be-
nign condition.
In contrast, there is the patient who receives,
but fails to accept the advice of radical operation,
and who drifts from physician to physician or
from quack to quack for help. When the condi-
tion is a benign one the patient may be cured of a
so-called “cancer” in spite and not because of the
physician’s advice, and therefore may be added
to the host of those who spare no effort to in-
fluence the laity against the recognized profes-
sion. She points to herself as a living example of
escape from cruel surgery. For this reason, the
blanket rule of prescribing radical operation in
all doubtful cases may act as a deterrent to those
who most need care and observation. Frequently,
the short delay in consulting the necessary au-
thority constitutes the difference between the
benign and the malignant stages of a tumor.
The public should be taught to come ; taught
that any lump is a great dauger; that to consult
a physician is the only safe method that an exam-
ination does not absolutely mean a radical opera-
tion. The profession must realize its respon.si-
bility and seek to deal with the individual case on
the merits of the conditions, present, in the light
of all that is known to medical science. It should
be equipped with all the facts — not those of ten
years ago, not those of yesterday, but the facts
of today, and adequately be prepared to meet
these seekers after truth by having at its com-
mand all the established current data of the pro-
fession, and then, only after deliberate considera-
tion of all the evidence obtainable, render the
verdict.
Medical knowledge concerning breast condi-
tions, is not sufficiently definite to warrant many
dogmatic conclusions. There is an accumulation
of material concerning which there is much aca-
demic disagreement. Information must be uni-
fied, standardized, and placed before the laity in
a form which is thoroughly comprehensible. Only
such vital phases of medical subjects as have re-
ceived the practical unanimous approval of the
profession should be released for the guidance of
the general public. It is an unfortunate fact that
some of the most eminent authorities disagree on
essential as well as on non-essential points. For
example, one surgeon states “that every lump
which appears in a woman’s breast should be re-
moved forty-eight hours after it is discovered.”
Another authority says, “When the question
arises between chronic mastitis and carcinoma it
is usually the safest procedure to remove the
breast, and * * * if no malignant process is
found, one has merely removed a menace to the
patient.”
In comparison, a well known author writes,
“Those who have served apprenticeships in the
laboratories of hospitals will admit, and all men
of experience know, that frequently radical oper-
ation is performed for simple lesions. I have ob-
served this in cases of single fibro-adenomas, in-
terstitial mastitis, and simple lobulation in a de-
veloping breast. Once I examined a pair of
breasts, removed from a young woman by a
specialist in diseases of children, and to this day
I have been unable to find any excuse whatever
for their removal. The Doctor was in doubt.
* * * I believe it is a greater error to subject
356
Journal of Iowa State Medical Society
[September, 1922
a young woman with a simple benign lesion to a
radical operation than it is to fail to extend to a
woman the 20 per cent chance in case of actual
carcinoma. * * * 'pj.jg platitude that it is
better to sacrifice a dozen suspected breasts than
to overlook a single case of carcinoma has long
served as a cloak for ignorance of the finer path-
ological changes in the gland.”
Recently, a leading pathologist made the state-
ment “that he based more faith on clinical meth-
ods, carefully applied by a skillful person, than on
other means of diagnosis at the present time. He
said it was a strange fact that the clinician always
insisted that the laboratory methods be applied
to diagnosis, while the laboratory worker favored
clinical methods — palpation, inspection and ob-
servation for a period of time, and that he had
spent a great deal of time in the laboratory and
preferred to base his diagnosis upon careful clini-
cal methods. There was, he supposed, a common
ground where laboratory worker and clinician
would some day meet.” * * * jjg added, “A
physician does not impress other physicians or the
public by applying the blanket rule to all breast
tumors and insisting that every lump in the breast
be excised. In distinguishing between malignant
and benign tumors of the breast it is important to
take into consideration the age of the patient, lo-
cation of the lump in the breast, consistency of
the tumor, history of the organ and all features
of the case and in this way one can usually reach
the diagnosis. The failure to recognize cancer is
often due to lack of proper physical examina-
tion.”
Howevei', the following radical views from
recognized authorities, have also been published:
“Cases of secondary hyperplasia should be con-
sidered as precancerous, and while they do not
require so extensive an operation as the removal
of the underlying muscles together with the axil-
lary glands, yet no portion of the mamma should
be left.
“In the surgery of mammary tumors, I am con-
vinced, however, that to insure the greatest good
to the greatest number, would be to advocate the
removal of every tumor bearing breast.
“Every benign tumor of the breast should be
removed before it has an opportunity to become
carcinomatous. In other words, it should be re-
moved as soon as recognized.”
At a recent medical meeting a surgeon said,
“that he would today submit every portion of a
breast with a blue dome cyst to careful micro-
scopic examination, and any breast, it made no
difference what the gross appearance, where
there existed one or a dozen cysts, regardless of
the size of the cysts, should always be examined
with the microscope. He had seen cysts removed
and the patient come back with cancer of the
breast.”
In answer to this statement, another surgeon
responded “that he did not care how the diag-
nosis was made, but if a whole breast must be
had for examination, how could the breast be
saved? The ‘take out’ policy would mean the
mutilation of every woman with a lump in her
breast.”
The foregoing are but a few of the radical and
conservative statements, the pros and cons of
which must be carefully weighed before any
definite conclusion can be reached. To radically
remove the breast in all doubtful cases eliminates
the development of malignancy for all time, and
therefore safeguards the surgeon’s reputation, but
is this attitude a just or a scientific one? Con-
sidering the patient and remembering the number
of unfortunate ones who have suffered unneces-
sary breast amputations, it seems imperative to
say that the radical breast operation should be
performed only after very careful consideration
of all signs and symptoms.
Many patients suffering from cancer come too
late, but it is equally true that there are changes
of the breast simulating cancer, and these must be
taken into consideration before making an ac-
curate diagnosis. The physician must be ever on
the watch for the frequent non-malignant breast
conditions. Abscess, actinomycosis, catarrh,
eczema, Hodgkin’s Disease, intestinal and other
toxemias, ovarian disease, menstruation, dis-
turbed endocrine function, hyperplasia, mastitis,
rheumatism, senile hypertrophy, congenital de-
formity, haematoma, traumatic fat necrosis, syph-
ilis, tuberculosis, simple lobulation in the gland
of the young maturing female, and the lumps
which are prone to remain in the mammae of the
child-bearing woman after lactation has ceased,
are causes which often create suspicious masses
in the breast region. To these may be added the
benign tumors, as : adenoma, chondroma, cysts,
fibroma, lipoma, myxoma, osteoma, and their
combinations, adeno-cystoma, fibro-adenoma,
cystic-adenoma, etc.
During years of practice the writer has exam-
ined large numbers of benign breast conditions,
many of which were referred to him as malig-
nant. Frequently, he has found it necessary to
reduce an inflammatory condition before defin-
itely deciding whether or not there was an under-
lying cancerous process. Some of the patients
had retraction of one or both nipples, and others
had one breast higher or larger than the other.
VoL. XII, No. 9\
Journal of Iowa State Medical Society
357
By obtaining a full history and with careful ob-
servation these conditions were proved to be of
congenital origin, and not in any way pathologi-
cal.
In a recent tabulation of the first 20CX) alpha-
betically arranged histories in the author’s office
files, the analysis showed 225 cases of benign
breast conditions, and eighty-five cases of mam-
mary malignancy. None of those diagnosed as
benign has, to the writer’s knowledge, developed
malignancy and all those clinically diagnosed as
cancer were proved to be such by pathological
examination of the specimen. The following il-
lustrative cases are reported in brief, covering
only the points relevant to this paper, not because
of the unusual aspects of the cases, but to empha-
size the fact that there are many pathological
changes in the mammae resulting from disorders
in other parts of the body, which, without careful
examination might be mistaken for cancer.
Note: In a paper read before the American
Association of Obstetricians, Gynecologists and
Abdominal Surgeons in September, 1920, I spoke
of the many breast lumps caused by stasis and
read reports of twenty-five cases, some of which
had been under observation from fifteen to
eighteen years, where the lumpy condition and
even well defined tumors of the breast had dis-
appeared under treatment for intestinal toxemia
1. Intestinal stasis cause of lumpy breasts.
L. F., age thirty-five, female, married, two chil-
dren, nursed both.
Patient consulted me March, 1920, for retraction of
and eczematous discharge from left nipple; consider-
able elongation and lumpiness of the upper, outer
quadrant of the breasts; two small glands felt in left
axilla.
Previous to consulting me the patient had seen two
well known surgeons, one of whom had advised radi-
cal operation, stating to her “that there was no can-
cer but that the breasts were no good and she might
as well have them off.” This surgeon also wrote to
the family physician: “I would urgently advise re-
moval of both breasts.”
.^fter careful examination of the patient, and
weighing well all the points. I was convinced that
radical operation was not called for and accordingly
recommended as follows: “Under no circumstances
at the present time, without a fair trial of prelimin-
ary measures, would I submit to operation. After a
month of treatment, we can definitely determine
what progress has been made.”
I then prescribed a brassiere to relieve all pull on
the upper, outer quadrant; bicarbonate of soda baths;
milk of magnesia internally; colonic irrigations;
tonics; wholesome diet; bland ointment on nipples
and large quantities of alkaline water, at the same
time impressing the importance for frequent examin-
ation.
July, 1920 the patient returned for an examination.
The lumps in the axilla had disappeared entirely; the
right breast was less lumpy; the left breast better; the
discharge materially lessened in amount and less ir-
ritating to the skin. The eczema about the areola
had disappeared; the feel of the breast was almost
normal and the general condition of the patient
good.
The results already secured in this case make it
clear that we have to deal with an inflammatory
and not a malignant process.
2. Stasis breasts.
C. B.,1 age thirty-seven, female, married, no preg-
Patient consulted me February, 1914, for a lumpy
condition of the left breast. There was also a mass
in the right mamma which a surgeon, whom the pa-
tient visited, declared malignant. As the tumor in
this breast was well defined, I advised conservative
operation. This was done and the pathological re-
port proved my diagnosis of benign neoplasm cor-
rect. After operation on the right breast, and medi-
cal treatment for intestinal toxemia, the left breast
cleared and in July, 1920, the patient reported both
breasts normal and her general condition excellent.
3. Stasis breasts.
A. B.,2 age twenty-five, female, widow, two chil-
dren, nursed both.
Was always constipated and in March, 1915, be-
gan to have severe pain in the right lower quadrant
of abdomen. In December, 1915, a lumpy condition
was noticed in left breast, with bloody discharge
from nipple, which was present when I saw the pa-
tient in February, 1916. There were also glandular
lumps in the upper, outer quadrant of the breast;
distinct tenderness in right iliac fossa, along the head
of the cecum and over the appendix. X-ray examin-
ation proved this a case of chronic intestinal stasis.
After abdominal operation there was a slight dis-
charge from the nipple for one week, after which
breast cleared up. Patient is now in perfect health,
and breasts are absolutely normal.
Previous to consulting me, this case was diagnosed
by several clinicians as cancer, and radical and im-
mediate amputation of the breast advised.
Note: It should be remembered that in a large
majority of cases some milk remains in the breasts
of women who have borne children and especially in
those who have nursed them. It is not the discharge
that is important, but the character of the discharge.
4. Congenital malformation of the breast.
H. S.,3 age thirty, female, single.
Patient was operated upon in 1915 for intestinal
stasis associated with a general lumpy condition of
I. Preliminary reports in “Cancer Problem’* and “Benign
Mammary Tumors and Intestinal Toxemia.**
nancy.
2. Preliminary reports in “Women’s Medical Journal,” May,
1917 and “Benign Mammary Tumors and Intestinal Toxemia.”
3. preliminary Report in “Benign Mammary Tumors and In*
testinal Toxemia.”
Journal of Iowa State Medical Society [September, 1922
358
the breasts. After abdominal operation, the lumps
in breasts disappeared with the exception of an en-
largement of the second costal cartilage under the
right breast, which, previous to seeing me, had been
diagnosed as a definite neoplasm. The characteristic
feel of this might easily have led one to believe that
it was an extension of a cancerous process from the
breast. However, after careful observation, I diag-
nosed it as a congenital malformation. It had not
changed in either size or form during my five j^ears
treatment of the case, and when I last saw her, both
breasts were normal except for this slight deformity.
5. Hodgkin’s Disease of the Breast.
E. N.,^ age thirty-two, female, married.
This patient, two years before consulting me, had
noticed an enlargement of the thyroid gland and
about a year later a tumor appeared on the right side
of the neck and another at the upper, outer margin
of the right breast, extending into axilla. Six months
previous to operation, a piece was taken from the
tumor in the neck at a hospital in a neighboring city.
The report was lympho-sarcoma, and the case con-
sidered beyond the hope of cure by operation. Pa-
tient grew steadily worse and exhibited pressure
symptoms in the neck. .\s a palliative procedure, 1
removed tumors as far as possible, with e.xtensive
ligation of large vessels, and applied radium. The
pathological report proved the case Hodgkin’s Dis-
ease. The patient lived for several years, but ul-
timately died of the disease which had extended into
many organs.
6. Lumpy condition of breast as result of tonsil
infection.
S. K.,5 age thirty-one, married, no children, female.
First consulted me in January, 1917, for lumpy con-
dition of both breasts. After operation for intestinal
stasis breasts cleared entirely and patient made excel-
lent recovery.
In 1919 she had influenza and later developed re-
peated attacks of infection of the throat. During
these attacks the breasts became lumpy and showed
a condition of mastitis throughout, as a result of
the tonsil infection.
7. Apparent malignant recurrence.
E. M., age about seventy, single, female.
In 1909 I removed the right breast of this patient
for carcinoma; the left breast had been removed
some years previous. Later an appendectomy was
performed.
In 1912 small nodules developed on the chest wall
over several of the costo-chondral articulations, near
the scars of the breast operations, more marked on
the right side. These w'ere considered by several as
malignant recurrence. The nodules were diffuse,
very tender and painful, especially in cold and damp
weather. I made a diagnosis of systemic condition,
and not of malignant recurrence. The patient was
kept under close observation and given treatment for
4. Preliminary report in “Conservation of the Human Breast,”
Int. Jour. Surgery, July, 191.').
5. Preliminary report in "Benign Mammary Tumors and In-
testinal Toxemia.”
acidosis. The lumps disappeared entirely, and the
patient is today perfectly well.
8. Eczema of the nipple.
K.,6 age twenty-six, female, single.
Patient had lumpy and painful condition of right
breast due to pyogenic infection from eczematous
ulcer of the nipple, which had persisted for some
weeks. Because of the appearance of the breast
and enlargement of the axillary glands, her doctor
advised removal of the organ for carcinoma. A few
days of proper treatment caused the eczema and
lumpy condition of the breast to disappear.
9. Syphilis of the breast.
P.,7 age thirty-eight, female.
Patient gave a history of having been well and
strong until two years before consulting me, when
she commenced having pain, more or less continu-
ous, in the upper part of the right breast. Examina-
tion showed enlargement of the external ends of the
second, third and fourth ribs on the same side. This
was verified by x-ray examination according to which
the pleura and lungs were not involved, and the
bone changes not sufficiently characteristic to justify
stating whether this was sarcoma or some benign
growth. Wassermann and Noguchi tests both prov-
ing positive, the patient was placed on iodid and
mercury and later given salvarsan followed by mixed
treatment. The enlargements, under these measures,
disappeared and five years later the patient’s physi-
cian reported her perfectly well.
10. Pelvic condition causing lumpy breasts.
A. S.,8 age thirty-two, female, single.
Two years before seeing me patient had an oper-
ation for a uterine condition. She consulted me July,
1919, for irritation of the bladder, severe pain in back
and ovarian region, together with a lumpy condition
of both breasts.
Laparotomy was performed, and I found a much
enlarged uterus with a considerable number of fungo-
sities, a mass of adhesions which extended back of
the uterus down to the cul de sac, a fibro-cystic right
ovary, deep in the pelvic cavity, surrounded by a
mass of omentum tightly adherent to the uterus in
front and to the rectum behind. The mass was about
the size of two hen eggs. The operative conditions
were corrected, and in .-August, 1920, the patient re-
ported that the lumps in the breasts had disappeared
entirely; she had gained twenty-seven pounds since
the operation and was in excellent condition.
11. Tuberculosis of the breast diagnosed as sar-
coma.
M. C.,9 age fifty-five, female, married, five children.
Examined patient who for three years had a hard
nodular swelling in the axilla, with involvment of
the breast, and who during these years, had been
6. Preliminary report in “Conservation of the Human Breast/'
Int. Jour, Surgery, July, 191').
7. Preliminary report in “Conservation of the Human Breast, ’
Int. Jour. Surgery, July, 191.5.
8. Preliminary report in “Benign Mammary Tumors and In-
testinal Toxemia.”
9. Preliminary Report in "The Cure of the Incurable/’
American Medicine, July. 1915.
VoL. XII, No. 9]
Journal of Iowa State Medical Society
359
operated on for this breast condition twice — a fistula
in the axilla following the first operation. When I
first saw the case, the mass was nearly the size of
the entire breast — painful on pressure. The arm, too,
was painful and much enlarged. Two specialists had
declared the case 'advanced sarcoma, one physician
telling her family that she could not live beyond a
few weeks. The patient was given morphine so that
she might be spared as much suffering as possible.
After careful examination I diagnosed the case as
inflammatory — possibly tuberculous — and decided to
give her a chance by extensive operation. This was
done and pathological report proved the diagnosis of
tuberculosis. After an uninterrupted recovery she
was discharged from the hospital in two weeks.
Two years later she was reported as well, but since
that time I have lost track of her.
12. Disturbed endocrine function causing lumpy
breasts.
L. N., age forty-two, female, married, one child.
Patient suffered from neurasthenia and hypo-thy-
roidism. Her weight increased until she averaged
two hundred pounds. There were lumps in both
breasts, and pressure on the mammae caused a cer-
tain amount of fluid to exude. The history of bloat-
ing, the added fat, the heart symptoms and the pig-
mentation and dryness of the skin all pointed to a
disturbance of the internal secretions. Thyroid and
multiple glandular secretion were administered and
the excessive fat reduced. As long as the patient
persisted in the treatment, the lumps in the breast
disappeared, but on suspension of the medication
they invariably recurred.
In August, 1920, the patient wrote that she was
continuously on the multiglandular treatment, that
she was in excellent condition, and that her breasts
were perfectly normal.
Note: In connection with this case, it is an inter-
esting observation that the masses in the mammae,
which were relieved on the basis of endocrine dys-
crasia, were in the same relation to the gland — up-
per, outer quadrant — as those resulting from stasis
or frequently seen during the catamenia.
Not only should the surgeon endeavor to be so
qualified as to recognize the benign and malig-
nant growths of the breast, as far as is clinically
possible, but he should also have a very definite
knowledge of the principles underlying the meth-
ods of examination. He should bear in mind the
fact that the very life of his patient rpay depend
upon the way he manipulates the tumor mass.
The patient herself, or the solicitous friend may
do damage by manipulating the breast, as may the
doctor when he examines the case, or the surgeon
when he operates. Nature erects natural barriers
to protect the various cells of the body, but
pressure along the blood-vessels or along the lym-
phatic glands may cause malignant growths to
reproduce themselves in locations other than the
original site, by extension through those channels.
Despite all that has been written on the subject
of biopsy, it is but a short time since the board of
health of a large city requested the profession to
cut into suspicious lesions — without one word of
caution about protecting the patient against the
possible spread of metasteses — and submit small
particles for examination, promising that a report
on the tissue would be forthcoming in from twen-
ty-four to thirty-six hours. Because of this at-
titude it seems necessary to emphasize once more
the extent to which a patient’s life may be jeop-
ardized by biopsy for the purpose of pathological
diagnosis. Cutting into a neoplasm of the breast,
or any other part of the body, may cause such a
dissemination of the cancer, if cancer be present,
that subsequent operation will be of no avail.
When the growth is at a difficult site, so that it
cannot be completely removed, and pathological
examination is necessary, the danger will be di-
minished by incising with the cautery knife or
cauterizing the cut surface — destroying all the
cells in the neighborhood and blocking the av-
enues of extension. A safer procedure is to
examine the specimen by the frozen section
method. However, there is also a chaotic state in
this particular field, for some pathologists refuse
to make a diagnosis on frozen section while
others feel it is safe to do so.
In the light of present knowledge may not the
following conclusions be drawn with safety, keep-
ing ever present in mind the terrible sword of
Damocles — cancer of the human breast?
1. The laity is coming earlier, in increasing
numbers, for examination.
2. Opportunity for service, on the part of the
medical profession is being increased in propor-
tion as the public responds to its summons.
3. The profession must develop a higher de-
gree of diagnostic ability than in the past and
possess itself of all the essential facts concerning
breast conditions.
4. A judicial attitude must be maintained —
careful examination with well poised judgment.
5. Accurate diagnosis of abnormal breast con-
ditions means and demands a careful systemic
survey as well as an efficient local examination.
6. The human mamma may be the seat of
changes purely inflammatory or of neoplastic na-
ture, closely simulating malignancy.
7. The relationship between the internal gen-
italia and the breast has been well established.
Correction of abnormal pelvic conditions may
ameliorate or relieve certain mammary changes.
8. The relationship between chronic intestinal
stasis and certain breast conditions seems to be
proved. Toxemia from teeth, tonsils and other
360
Journal of Iowa State Medical Society
[September, 1922
parts of the body, may also have its effect upon
the mammary gland.
9. Serious conditions are often overlooked
while they are as yet amenable to the simplest
measures of non-surgical treatment.
10. The use of the terms “breast” and
“mamma” as synonomous may increase the diffi-
culties of diagnosis. The writer believes it would
be helpful to confine the term “mamma” to the
gland with its ducts, includin its outlet, the nipple ;
“breast” as embracing the entire “mamma” with
all else that surrounds it — the skin, fat, fascia,
capsule, and the bed upon which the gland rests,
the fascia, muscle, and bone with the cartilage, in
juxtaposition to the “mamma.”
11. Any of these structures may be diseased,
and a multiple pathology be present, rendering
diagnosis more difficult.
12. Abnormal conditions, congenital or ac-
quired may be present in neighboring structures,
and lead to wrong diagnosis of cancer, or <f
malignant disease is present, lead to the diagnosis
of the inoperable and incurable stage although the
neoplasm is early and surgically curable.
13. In spite of present knowledge, it is impos-
sible at times to arrive at an immediate accurate
diagnosis. In justice to the patient it may be
necessary to keep her under careful observation,
treating general conditions, before proceeding to
radical surgery. If then, mistakes will occur, it
should be the earnest endeavor of the profession
to make them fewer and fewer.
14. It is reasonable to assume that with the
early recognition of some lumpy conditions of the
breast, followed by adequate systemic treatment,
and mechanical support, underlying factors of
malignant disease may be removed.
15. A question naturally arises: If all the
foregoing is true, may it not be that in that mul-
tiplex disease grouped toda)^ under the term “can-
cer,” there are possibly causative factors under-
Ij'ing malignant disease in the toxemieas and the
heterological activity of the endocrines. This
seems to be a very promising field of research.
16. When cancer is present beyond a reason-
able doubt, radical surgery is absolutely indi-
cated.
To allow a patient to drift beyond the hope of
surgical cure is a terrible tragedy ; to unnecessar-
ily and radically remove a woman’s breast may
be a profound calamity. With a deep sense of
the limitations in the art of exact diagnosis arid
of the greater responsibility today in the enlarging
field of service for humanity, let the profession
ever be guided by the watchword “Not Fears but
Facts.”
SUPPL\PUBIC PROSTATECTOMY : TECH-
NIC AND AFTER RESULTS*
George E. Decker, 1\I.D., Davenport
Patients presenting themselves for relief of
prostatic obstruction may be divided into two
groups : those whose bladders are not yet in-
fected and those having more or less cystitis.
The clean bladder has a thin, possibly atonic,
wall and admits of almost unlimited dilatation.
Such a bladder may present the condition of re-
tention with overflow, the residual urine in some
cases amounting to forty or fifty ounces, while
the amount voided at each attempt at urination
is but an ounce or two. With marked over-dis-
tention of the bladder the back pressure on the
kidneys is considerable ; however it has developed
and increased ver}^ gradually and the kidney has
in the same gradual way managed to overcome
the pressure and maintain its secretory function.
The infected bladder has usually become so
through catheterization or other attempts at re-
lief and its wall is thick and inelastic and does
not admit of marked distention. The amount of
residual urine is small compared with that found
in the clean, thin walled bladder, but the symp-
toms are usually much more urgent because of
the intolerant condition of the organ. The pain
and suffering and the resulting loss of sleep adds
greatly to the systemic effects of the infection it-
self. Back pressure on the kidneys is of less im-
portance than in the clean group of cases.
It is true that a clean and over distended blad-
der may become infected and then soon becomes
contracted, but an infected and contracted blad-
der practically never dilates. The above general
consideration of the bladder condition found in
prostatic obstruction leads to the conclusion that
all supra pubic prostatectomies should be done by
the two step method and for the following rea-
sons :
In the clean class of cases the patient rarely
presents himself until back pressure on the kid-
ney has developed. The sudden relief of this
back pressure by emptying the bladder or by
suprapubic drainage seriously upsets the balance
of kidney function, a renal congestion occurs and
excretion may almost cease for a time. If to
this disturbance of kidney function is added the
shock of operative removal of the prostate the
combination may overwhelm the patient, espec-
ially if he be an old man. Therefore an over-
filled bladder should be catheterized very cau-
tiously, an increasing amount being removed once
*Read before the Seventieth Annual Session, Iowa State Medical
Society, Des Moines. Iowa, May 11^ 12, 13, 1921.
VoL. XII, No. 9J
Journal of Iowa State Medical Society
361
a clay until on the third or fourth day it is com-
pletely emptied. Only after a day or two of com-
plete catheterization can suprapubic drainage be
done safely and even then the average patient ex-
periences cjuite a disturbance. There is a differ-
ent reason for preliminary drainage of infected
cases and since back pressure is not an element,
preliminary catheterization is not necessary.
Free and continuous drainage rapidly reduces in-
fection, after which the prostate may be safely re-
moved.
General anesthesia is not required for the pre-
liminary cystotomy. Infiltration with one-half
per cent solution novocain with adrenalin is
done while the patient is in his bed. Twenty or
thirty minutes later he is taken to the operating
room, the bladder emptied by catheter and filled
with saturated boric acid solution. This holds
the bladder wall well up above the symphysis,
permits of very gentle technique in opening into
the bladder cavity and also floods the operative
wound with a clean fluid instead of urine. A
mark with an anilin pencil one inch from the end
of the drainage tube survives the boiling and per-
mits of accurate adjustment of the tube in the
bladder, as it can then be sewed to the fascia over
the recti muscles with the certainty that its inner
end is not pressing upon the base of the bladder
and rendering the patient miserable. The tube
stitch of chronic gut is in the fascia and not in the
skin as the patient will be out of bed in a day or
two and will be very unhappy if every move of
the tube saws the stitch through the sensitive
skin. Bladder wall, muscle fascia, and skin are
sewed snugly about the tube and a water tighr
joint results which is very satisfactory.
The reaction which often follows this simple,
painless and bloodless procedure is all out of pro-
portion to the extent of operative disturbance of
tissue and is evidenced by nausea, anorexia,
marked reduction of urine quantity and an in-
crease in albumin and tube casts in the urine.
This reaction is the result of the sudden imbalance
into which the kidney is thrown when the back
pressure of months or years is suddenly reduced
to zero. The patient with the infected bladder
has but little “imbalance reaction” his greatest
risk being e.xtension of the infection into the pre-
vesical space of Retzius. To avoid this, coapta-
tion of tissues about the tube should be accurate
and a wider tube used than in clean cases.
The interval between the preliminary cystot-
omy and the removal of the prostate should be
long enough to permit the patient to reach the
best physical condition possible and this may be
measured by his subjective symptoms. Temper-
ature, pulse rate, blood-pressure, thalein output,
are imixjrtant and should be noted from time to
time but if the patient does not volunteer the in-
formation that he feels better and if he does not
develop an appetite for three fair meals a day his
condition does not yet warrant the second oper-
ation.
It is the writer’s opinion that return of appetite
and a cheerful and hopeful outlook are the two
symptoms that best determine the safety of
further surgical interference.
Prostatectomy itself is never an emergency
procedure and, except in case of intra vesical
hemorrhage, even the cystotomy may wait upon
the careful preliminary catheterization. There-
fore, the patient’s safety must never be jeopard-
ized by over-anxiety to complete the job; the
operation is divided into two steps for a definite
purpose and the proper interval is the one that
achieves this purpose however many days or
weeks may be required.
The removal of the gland is done under general
anesthesia, preferably gas-oxygen after a pre-
liminary hypodermic of pantopon or morphine.
The bladder is washed out with boric acid solu-
tion and the suprapubic wound enlarged so that
the bladder may be explored by the finger. The
left hand, covered by two new rubber gloves, in-
troduces two fingers gently into the rectum while
the right hand, bare, introduces the index finger
into the prostatic urethra. The prostatic urethra
splits and permits the finger to find the line of
cleavage between the gland and its sheath.
Enucleation may be completed in two or three
minutes or may present considerable difficulty,
but in any case the bimanual procedure here de-
scribed permits of co-ordination between the
operator’s two hands, which is impossible if an
assistant attempts to support the gland through
the rectum. By the use of two gloves on the left
hand all danger of soiling is avoided and in the
later stage of the operation these gloves may be
quickly replaced by a fresh one.
It is a distinct advantage to begin the enuclea-
tion on the far side of the gland, working toward
oneself, and having the nearest and easiest part to
do last, when the finger becomes tired.
As long as the gland is attached to the urethra
it remains snugly in its place though separated
from all its other attachments and while thus in
place serves to restrain bleeding in the same way
as do the Hagner rubber bags. After the urethral
attachment has been severed and the gland is
free in the general cavity of the bladder, the pros-
tatic cavity or pouch is quickly massaged biman-
ually, much as a bleeding uterus is managed, and
362
Journal of Iowa State Medical Society [September, 1922
in a few minutes the cavity is so contracted as
barely to admit the finger tip. Xo effort is made
to remove the gland from the bladder nor to re-
move the left fingers from the rectum until the
prostate cavity is well contracted.
An assistant now introduces a full sized soft
rubber catheter through the urethra and the
operator, by means of the fingers still in the
rectum and the right index finger in the bladder,
guides the catheter into the bladder where it is to
remain for two to three days. Bleeding being
controlled and the catheter in place, it is proper to
remove the gland and larger clots from the blad-
der and introduce the large suprapubic tube. The
same caution is used to avoid pressure of the tube
against the base of the bladder and the tissues are
brought together around the tube in three layers.
With catheter and tube in place the bladder is ir-
rigated with hot boric solution just enough to as-
sure the patency of both tubes after which a
voluminous dressing is applied. The suprapubic
drain is attached to a tube running to a recepta-
cle at the bed side, and particular care is taken
that the glass connecting tubes have the widest
possible lumen. The end of the catheter is bent
over and included in the dressing.
A\hthin eight or ten hours irrigation should be
done through the catheter to assure the absence
of clots in both tubes and is repeated whenever
drainage is interfered with. Free drainage is
very essential, in order that the prostatic cavity
may not be distended and bleeding started or pro-
longed. The patient’s discomfort and pain is the
surest sign that the tubes are obstructed and ev-
ery effort must be made to clear the tubes and
restore comfort.
X"o irrigation is used after the second day, as
the blood no longer clots and the tubes remain
clear. The catheter is removed during the third
day after operation, and is well tolerated if both
tubes are kept clear. The pain attributed to the
catheter in the urethra is more often due to
faulty drainage and intra-vesical pressure.
Usually the red color of the drainage disap-
pears in about five days, and the suprapubic tube
may be removed and the wound encouraged to heal.
A little urine finds its way through the urethra
about the twelfth or fifteenth day after operation,
and free urination is established by the twentieth
or twenty-fifth day. Epididymitis is a frequent
and serious complication. It is caused by exten-
sion of infection from the prostatic cavity down
the vas and is more frequently seen if mucn
urethral irrigation is done.
Late contraction of scar tissue at the bladder
outlet occasionally requires gradual dilatation
with sounds, though this complication is less fre-
quent than might be expected.
Conclusions
1. Prostatectomy is never an emergency oper-
ation and permits ample preparation of the pa-
tient.
2. Preliminary suprapubic drainage re-estab-
lishes kidney function and reduces cystitis.
3. The interval between bladder drainage and
removal of the gland should be long enough to
restore the patient to health.
4. Bleeding at operation is best controlled by
bimanual massage of the prostatic cavity.
5. Free post-operative drainage must be as-
sured, but irrigation is used only to clear the
tubes.
6. Every detail of technique which adds to
the patient’s comfort decreases the operative risk.
ECTOPIC GESTATION AS A VITAL SUB-
JECT TO THE PATIENT AND TO THE
PRACTITIONER*
Coral R. Armentrout, M.D., Keokuk
Ectopic pregnancy is one in which the fecun-
dated ovum develops outside the uterine cavity.
These ca.ses are divided under three heads,
tubal, ovarian and abdominal.
Tubal pregnancy develops in some portion of
the tube, it is the one occurring most frequently
and is caused by the lodging of the ovum some-
where in the tubal canal.
Ovarian pregnancy occurs in the ovarv- itself
but this is an exceedingly rare condition.
Abdominal pregnancy is secondary to rupture
of a tubal pregnancy, or to a tubal abortion.
Tubal pregnancy is found most frequently in
the central part of the tube, occasionally near the
fimbriated end and when it occurs there the
ovary forms a part of the sack wall, and more
rarely we have the ovum lodging in the uterine
end of the tube. It will be seen therefore that
abdominal pregnancy is really only a follow up
of the first classification as I question whether
an abdominal pregnancy would ever occur except
following a tubal abortion.
Inflammatory changes in the tube which have
destroyed the cilia are accepted as one of the pre-
dominating causes of arrest of the ovum through
the tubal canal, but any condition which arrests
or delays the transition of the ovum from the
ovary to the uterine cavity is a causative factor
•presented before the Seventieth Annual Session, Iowa State
Medical Society, Des Moines, Iowa, May 11, 12, 13, 1921.
VoL. XII, No. 9]
Journal of Iowa State Medical Society
363
in its establishing itself in some location beyond
the uterus.
M'hen the fecundated ovum, covered with ecto-
dermal cells or trophoblasts become fixed in the
tube, it cannot eat its way into the structure of
the tube as it does into the uterine mucous mem-
brane, consequently, there is an absence of de-
cidua.
Then as the ovum develops the walls of the
tube are gradually thinned and may be perfor-
ated by villa, which condition itself may be the
cause of rather profuse hemorrhage.
The walls of the tube are capable of a fairly
limited degree of dilatation, so that a rupture of
the tube usually occurs about the sixth week or
shortly after this time.
If the attachment of the ovum is near the fim-
briated end of the tube, a tubal abortion is likely
to occur at about this time, with a discharge of
the sack into the cavity of the abdomen, thus if
the pregnancy continues it is changed from a
tubal to an abdominal type.
A pregnancy occuring near the corner of the
uterus may dilate the uterine end of the tube so
that it will be discharged into the uterine cavity
where it may continue to develop as a uterine
pregnancy. This fortunate occurrence however,
is very rare. It may rupture into the abdomen
as in pregnancy in the center of the tube, with
the exception that the hemorrhage from a rup-
ture in this location is usually much more violent
than from the one at the center of the tube or
from the one at the fimbriated end.
There are some rather definite symptoms of
ectopic pregnancy that I have found to exist in
the cases I have seen, which can be brought out
by a careful case history of the preceding weeks
of the patient.
1. A definite history of pelvic disturbance
which can nearly always be diagnosed as tubal
trouble of some kind, and which often dates back
a good many months from the present occurrence.
2. An irregularity of menstruation, continu-
ing for some months before the present disturb-
ance, and with the onset of the present trouble a
discharge of dark colored blood occurring each
day, with no clot and no regular menstrual flow.
3. Changes in the breasts indicating a preg-
nancy, and occasionally the vomiting of preg-
nancy which, however, is not at all a constant
symptom.
4. The occurrence of a sudden sharp pain in
the lower abdomen, which is followed by the
symptoms of shock from hemorrhage, the degree
of shock depending on the amount and sudden-
ness of the hemorrhage.
It is the occurrence of this sudden pain, and the
physical condition following it, that more often
brings the family doctor into the case and often
his immediate diagnosis and action determine the
future of the patient.
If the hemorhage is not too great the patient
may go on to recovery though it will surely take
months before the debris and clots will be ab-
sorbed, and then adhesions, obstructions and
many other ills may come from the inevitable in-
flammatory action in the effort of nature to do
away with the foreign body.
The physical examination will vary according
to the length of development of the pregnancy
and whether or not a hemorrhage has already oc-
curred.
There will be an enlargement on the side of
the pregnancy the same as may come with a pyo-
salpinx on one side.
The uterus is slightly enlarged and heavy. If
a rupture has occurred the cul-de-sac may be
filled with clotted blood presenting a soft boggy
mass. Usually an acute tenderness on pressure
over the affected side. '
The diagnosis may be made prior to the rup-
ture, at the time of rupture, or later during the
development of the fetus. It is my experience
that only a very few are seen before rupture oc-
curs so that the diagnosis is principally of a rup-
tured case, which gives the history" above out-
lined with the addition of a sudden sharp pain in
the lower abdomen that the patient themselves
can locate as being on one side or the other,
which is followed by faintness, or actual fainting,
and if a severe hemorrhage, by profound shock
with evidence of an internal hemorrhage. If the
condition improves, bleeding may occur again
when the blood-pressure raises or when for some
reason the blood clot becomes loosened.
A ruptured pregnancy of the right tube may
be mistaken for a ruptured appendix. I have
seen this diagnosis made a number of times. Also
I have had two cases of ruptured ovary with se-
vere hemorrhage and it is almost impossible to
differentiate between these conditions.
A patient with salpingitis may give nearly the
same history, including the pain low down and
blood discharge from the uterus. One case I
have had recently, where all these symptoms were
present, even to bleeding into the tubal cavity
■which was repeated several times. The single
exceptions I would say were that there were no
changes in the breasts and the mass in the cul-
de-sac was harder than that caused by a hemor-
rhagic mass.
In the treatment of this condition, it must be
364
Journal of Iowa State Medical Society
[September, 1922
recognized as a highly dangerous one, and cer-
tainly one in which we cannot feel that there is
much safety in delay though Warbasse tells us
that nearly 95 per cent recover if let alone. I
have to say that the cases I have seen are nearly
all in the extra 5 per cent, as the ones which have
gone for sometime, still come to operation for in-
fection of the clots. Unfortunately, where we
have to see these cases in private practice, and
many of them outside of the hospital, rather a
different line must be followed than if they were
all under ideal conditions. It has fallen to my
lot to have twelve of these cases come up in my
practice, all of them being referred except one,
and although the number is not large, it is enough
to warn one that this is not a rare condition, that
we do not need to watch for, but that if we are
not on the alert at all times to make an instant
diagnosis, we may easily lose one of them before
we make up our minds what condition we have
before us.
Also one comes to some rather definite conclu-
sions as to the treatment of them, after seeing
some of these sudden, ^reat hemorrhages with
the collapse of the patient, and death staring
them in the face.
One of my cases I operated on within a hour
of the rupture, and on opening the peritoneum the
blood gushed out as from a large artery, it was
under so much tension that only a short time of
waiting on this case would have meant certain
death, ami no opiwrtune time would have come
for this case, except at once.
Then a case representing the other extreme
had gone for ten days with a fresh hemorrhage
occurring as soon as the blood clot was loosened
by pressure or movement, and the patient grow-
ing weaker and weaker each day until she was
not only pulseless but seemed to be entirely
bloodless so that it seemed if anything was ever
done for the woman it must be there and at once,
so a frame was built to be used on a dining room
table to give extreme Trendelenberg position, the
abdomen was opened, the hemorrhage stopped
and clots removed in a few minutes. The patient
was left on this frame which was put on the bed
for several hours continuing hypodermoclysis
that had been started as soon as the hemorrhage
ceased and aided by water by drop method by
rectum. She was left in this position for about
twelve hours in all and finally rallied nicely.
However, it would have been much easier and
safer to operate on the day of rupture if a diag-
nosis had been made at that time.
Two cases had gone until infection had oc-
curred in the blood clots and violent jieritonitis
had ensued. The infection was probably of old
tubal origin to which the systems had become
vaccinated, or they would probably not have lived
long enough to come to operation.
One case was the rare kind of ovarian preg-
nancy with an early rupture and not so violent a
hemorrhage as occurs from the central tubal
origin. The other seven cases were all of tubal
origin and all operated upon early, the most of
them within a few hours of the accident and the
post-operative history in each was as uninterest-
ing as that of an ordinary clean appendectomy.
I have always felt considerable pride in the fact
that all twelve of these cases made a satisfactory
recover}-. If one could have these cases in the
hospital where they would be under constant ob-
servation it might be safe to let them go to an
apparently more convenient time, but unfortun-
ately work referred from the small town and
country side is sometimes far from hospitals and
it would be murder in some of these cases to at-
tempt moving them on a local train, in a baggage
car traveling over a rough road, and each jolt
helping to loosen a clot if one forms, so many of
these cases may have to be taken care of where
they are found, for if the first hemorrhage should
stop and the patient is six or seven hours away
from the surgeon it is not safe to leave them,
also not safe in many, cases to move them.
Unfortunately referred work from the country
is emergency work and must be done on the
ground, so to speak, and ideal conditions depicted
in literature cannot be realized, but the general
practitioner and the local surgeon have to con-
sider not how a patient could be handled under
ideal conditions, but how best to save the life of
the patient in an extreme emergency.
The technique of operation I have followed in
these cases is nearly the same in all cases, a quick
opening of the abdomen, usually the medium line,
or possibly through the rectus muscle of the af-
fected side if this is preferred. The immediate
clamping off of the bleeding tube followed by its
removal and closing over the raw surfaces. If
the ovary is undamaged it should be left. If the
patient’s conditions permits, the opposite tube
should be examined, and if diseased, it should
also be removed, but if no evidence of disease is
found I see no reason for removing all hope of a
future normal pregnancy, because there has been
an unfortunate accident on the other side, also
if time permits, I do not believe in leaving a large
clot in the cul-de-sac as a possible focus of in-
fection. It is also a good plan to fill the abdo-
men with normal salt solution before closing.
VoL. XII, No. 91
365
Journal of Iowa State Medical Society
The post-operative treatment is no different
from any other abdominal cases except where
there has been an extreme hemorrhage with shock
thev require more supportive treatment for the
first few days, and later, a full and especially
nourishing and blood building diet until normal
health has been regained.
Last Friday forenoon I was called twenty-five
miles into the country, to see what proved to be
another ruptured extra uterine pregnancy, so I
add a short history of her case to this paper as
it adds one more to the series.
Mrs. J. E. W. aged thirty-six, had for some months
had pain and trouble in the pelvis with a great deal
of hemorrhage at times. She had a diagnosis of
fibroid uterus. Last month she missed her men-
strual period altogether but for over two weeks now
has been flowing constantly, the flow being dark
colored and sometimes quite free.
This morning (Friday) at about nine o’clock she
was as well as usual and was out in the pasture with
some of her children, and while sitting down to rest
had a sudden sharp pain low down on the right side
and fainted in about ten minutes, and has been in
complete collapse every since.
She was carried into the house and her physician.
Dr. I. F. Thompson, called at once. He arrived
about 11:30 and diagnosed the condition as internal
hemorrhage from a ruptured extra uterine pregnancy.
He called me and as soon as instruments and packs
could be obtained from the hospital the trip was
started. The patient was pulseless at the wrist and
had every evidence of collapse and although the rup-
ture had occurred some hours before there was no
sign of reaction, she seemed to be getting worse, so
the dining room was cleared out hurriedly, a trestle
made to raise one end of the table to give Trendelen-
burg position, and the abdomen opened at 2:30 p. m.
Found it full of blood with some old clots showing
that there had been leakage through the end of the
tube before the rupture. The pregnancy was near
the uterine end of the tube, which accounted for the
extreme hemorrhage and profound shock so quickly
following the rupture. I removed the ruptured tube
and the ovary and cleaned out the large clots in the
cul-de-sac, the entire operation consuming only thir-
teen minutes. It was also found that the diagnosis
of fibroma was correct. At the last report the pa-
tient was doing very nicely and apparently is to
make a good recovery.
Conclusions
1. Be suspicious of every case which gives a
history of irregular apparent menstrual flow,
followed by several weeks more or less constant,
dark in color.
2. When the sudden sharp pain in the lower
abdomen occurs followed by shock and hemor-
rhage, don’t delay but get the best help available
to share the responsibility of deciding the imme-
diate future of the case.
3. It is my belief that the life as well as the
future of these cases can be best conserved by
early operation.
Discussion
Dr. H. W. Barbour, Mason City — Ectopic gesta-
tion is a condition that carries with it many diffi-
culties in diagnosis. It is a condition we should all
be on the lookout for. The indications are to go in
when the diagnosis can be made, and as soon as the
bleeding vessels are tied we should get out. I agree
with the essayist on the after-treatment. If the pa-
tient is in shock from hemorrhage, a blood transfu-
sion is indicated.
Dr. E. C. Junger, Soldier — I want to come to the
defence of the general practitioner and see if you
do not agree with me that we are sometimes up
against it. I practice among people that are mainly
Norwegians, they are quite clannish and do not often
leave home, therefore they do not get any of these
new-fangled ideas. Whenever w'e are called upon to
do something that is new or different or out of the
ordinary, we have to be readj”^ to take a lot of blame
if things go wrong. I do not know why, in the
nineteen years that I have been in practice, I should
have had a case of ruptured tubal pregnancy the first
year and then not any in the next eighteen years.
This happened, as these things sometimes will, on
a Sunday morning, when we have no trains, and at
that time we had no telephone, no automobile, no-
body we could get hold of. Procuring a livery team,
I reached the patient in due time. The pain was on
the right side, and the first physician called had the
previous evening (Saturday) diagnosed the condi-
tion appendicitis. On Sunday morning at 5 a. m. I
found the patient in shock. She was a big, stout,
well developed Norwegian woman who never had
paid attention to any little pain. Whenever you are
called to treat a Norwegian, make up your mind that
the patient is sick. I must say that I made a bril-
liant diagnosis, for once at least, based on the condi-
tion of extreme shock. This woman had eight chil-
dren, step-ladder fashion, the baby only a year old.
I said to the Doctor, “This looks like a ruptured
tubal pregnancy.” We had a little history, but it is
difficult to get a history from some of these people,
they do not pay any attention to when they men-
struated last. It took several hours to secure con-
sent of the family to operation. Then when I had
gained consent I needed a man to give the anes-
thetic, I wanted a nurse, and had to go home after
the instruments. Nevertheless we got in there be-
fore noon, the patient’s abdomen about as large as a
pregnancy at term from accumulation of blood. In-
stead of finding the lesion on the right side, it was
the left tube that was ruptured. I got enough blood
out of the road to get to the tube, tied it off and got
out, leaving in considerable blood clot, which, ab-
sorbing, answered instead of feeding the woman a
lot of hoemobeloids at $1 per bottle. I also used
366
Journal of Iowa State Medical Society
[September, 1922
normal salt solution by bowel and hypodermoclysis.
The patient made a good recovery and has since had
two fine babies. The woman ought to have a Roose-
velt medal, and I ought to be cited for special
bravery under unusual circumstances.
Dr. B. D. Atchley, Shelby — My people in Shelby
are losing what little faith in me they ever had. I
was there seven j^ears before having a case of tubal
pregnancy. Then I had one, and, as Dr. Junger just
stated, it took about five hours to get consent to an
operation. The patient made an uneventful recovery
and is now pregnant again. But the loss of faith
came a short time ago when my third case of tubal
pregnancy was operated on, then in four months we
had to operate on the other side for a similar con-
dition. Since that I have had another case of tubal
pregnancy, therefore all these cases, coming within
such a short time as they did, makes me sit up and
take notice. I now dread to see a female patient
with a little hemorrhage and pain in the side because
of fear of tubal pregnancy. But it may be of interest
to the men here to know that we fellows in the coun-
try sometimes get these cases in groups, and that
they are rather trying.
Dr. Armentrout — The case cited by Dr. Junger em-
phasizes the point I intended to bring out: That
these things have to be taken care of at the time and
under the best conditions one can get, because with
many of us much of our practice is a considerable
distance from the hospital, and therefore we have to
use what we have at hand. We cannot have things
the way we would like to have them, and my idea in
presenting the paper was simply to bring to our
minds that this is not at all a rare condition as it
was supposed to be when I was in school. Sooner
or later every one of us is going to see some of
these cases, and if we do not keep an open mind on
this condition, sometime one of these patients will
slip away from us.
OBSERVATIONS BY A WOMAN PHYSI-
CIAN IN STATE HOSPITAL FOR
INSANE
Pauline Leader, ^I.D., Clarinda
It has been observed and is a fact, that the ma-
jority of the laity, and even some doctors and
nurses, do not think of, or look upon the mentally
afflicted as one that is sick, and needs to be
cared for, and treated like a really sick person —
just one with an addled brain, or “daffy,” as they
term it. They will tell you there is nothing the
matter with the person, only he has an ungovern-
able temper — is acting queer, or mysterious, and
has some silly ideas in his head that he keeps re-
peating.
This is a great mistake, for there is no sickness
compares with some forms of mental sickness —
no suffering or pain so great as mental pain.
Take for instance, the person suffering from
that form of mental trouble classified as pure
melancholia. The very countenance and expres-
sion of the face bespeaks their agony and mental
suffering; and when one sees them, one cannot
help but to some extent suffer with them. With
this form of mental trouble or sickness, there is
a gradual development of a state of apprehensive
depression, associated with more or less fully
developed delusions. The most common of these
are ideas of sin, such as ideas of having fallen
away from God, of being forsaken, having com-
mitted the unpardonable sin, of being possessed
of the devil ; hypochondriacal ideas, of never be-
ing well again, never can eat another meal, of
having no stomach, no brain, etc. There is often
apprehension of poverty, of having to starve, of
being thrown into prison, and of execution.
As a consequence of this mental unrest, and
these tormenting ideas that prey on them day and
night, there almost invariably develops the wish
to have done with this life, and patients very often
become suicidal ; and the one class of mental pa-
tients that need to be most closely guarded, to
prevent suicide, is the pure melancholia.
Can anyone who is possessed of normal mind,
conceive of anything more painful, more distress-
ing, than something preying on their mind day
and night — something that cannot be forgotten
or gotten rid of ?
For the majority of severe physical pains, there
is some medicinal preparation that may be admin-
istered, that acts as a panacea for the same, but
not so with mental pain. There is no one thing
in the medicinal curriculum, that will obliterate
the pain of the mind.
It has been observed that the doctors and
nurses that devote their time to the mentally sick,
are sort of held aloof by some from other work-
ers in the medical field — are thought of as not
amounting to much, or standing very high in the
scale of the medical profession — are just “crazy”
doctors, and “crazy” nurses.
Let one who has plowed in both fields, state
that it takes more tact, more skill, more patience,
more sympathy, and more of the attributes of the
Great Physician, to successfully treat and care for
a mentally sick patient, than it does to treat a
case of small-pox, an ingrown toe nail, or a
broken bone. It is the difference between treat-
ing a patient with an arranged mind, and one
with a disarranged mind. It is the difference
between treating the coarser parts of the body, as
it were, and the choicest, most wonderful, most
VoL. XII, No. 9]
Journal of Iowa State Medical Society
367
precious possession that mankind has — the mind
itself.
The mental doctors must have a broader knowl-
edge than just that which pertains to mental dis-
eases alone — for the mentally sick are not im-
mune from other diseases of the body. They
must have a working knowledge of the different
diseases, and know something of internal medi-
cine; for sometimes a patient is brought into the
hospital, suffering from typhoid, or some disease
mistaken for mental trouble. Sometimes there
is an epidemic in the hospital, of typhoid, or flu,
some small-pox, and other contagious and infec-
tious diseases.
They must know something of surgery, as there
are always cases of plastic and minor surgery,
and occasionally a case of major surgery. They
must, like the osteopath, know something of
anatomy, as there are sometimes dislocations to
reduce, and broken bones to set.
The disease in the individual must be treated,
and not solely the mental symptoms. Syphilis of
the brain must be treated with the same remedies
as syphilis in any other part of the body. Ty-
phoid fever of the insane must be treated like
typhoid fever of the sane, and so on.
The mental cases suffering from these various
physical diseases, cannot be sent to a general hos-
pital, but must be treated in their own hospital ;
hence, the psychiatrist must be able to diagnose
and treat these diseases. The general practi-
tioner of medicine is frequently called upon to
treat cases of mental diseases; he may be con-
fronted by a confusing array of symptoms of a
psychical nature, with which he may or may not
feel able to cope — but he has the advantage of
sending his case, as soon as he recognizes some
mental disturbance, to the hospital for the men-
tally afflicted, and he does not have to be able to
diagnose the case, as to whether it is a case of de-
mentia praecox of the hebephrenic form, kata-
tonic, or manic depressive, or what it may be.
It is true that the average medical graduate of
today has a far better knowledge of mental dis-
eases and their classification, than the graduate
of yesterday. This is due largely to the fact, that
in some medical colleges, especially the state col-
leges, there is, in connection with it, like in our
good State University of Iowa, a psychopathic
department, where patients with some mental and
nervous trouble can go, of their own free will,
and without being committed, and be examined
and treated for a time — thus giving the students
an opportunity to observe and study mental and
nervous diseases. It would not be amiss to say,
that Iowa may congratulate herself for thus being
able to secure the services, and bring to the West,
the very efficient psychiatrist she has at the head
of her new department.
As a whole, no class of cases probably make
better response to proper medical attention given
at the proper time, than those belonging to the
so-called “insane.” The cases must come early,
while the symptoms are in the acute stage, and
not be allowed to drift into incurability, while
waiting at home for a change for the better to
take place. This does not mean, or have refer-
ence to the case with decayed or defective brain,
in which there is nothing to treat but cases with
derangement of the mental faculties.
It is observed that those who work with the
mental cases become unconsciously sort of char-
acter readers, as it were, due to the habit of
closely observing the mentally deranged. They
must do this to know something of their physical
ailments, for many will not make manifest their
ailments or sufferings, if they could.
Those with religious delusions think they are
serving by suffering. One has to deal with the
objective symptoms, rather than the subjective.
Sometimes there are deranged cases that are re-
stored mentally by severe pain, suffering and ill-
ness. On the ward walks, one becomes accus-
tomed to observing closely for some symptoms of
improvement. There may be a more kindly ex-
pression, or a twinkle of the eye, or a skeleton
of a smile that had not been in existence previous
to this. A more erect posture, or a quickened
step. These minor things do not seem much in
the abstract, but in the aggregate, they are like
the “Little drops of water, and the little grains of
sand,” that you remember “make the mighty
ocean, and the pleasant land.” So these little
marks and symptoms in the aggregate, often be-
speak recovery.
It is to be noted, that of the number of women
that are committed to the Iowa state hospitals for
nervous and mental treatment, there are very few
women, as compared with the number of men, that
are suffering from venereal disease, or paresis.
This, at least, is true of the Clarinda State Hos-
pital, and it gleans from some of the largest cities
and towns of the state. As a rule, we do not re-
ceive these cases until the usual somatic and
psychic signs are very marked, and the disease,
especially that of paresis, well on its way, or fully
established. There is a slow, continued physical
and mental decadence. The clinical course of
most every case of paresis, has periods when the
coherent, intellectual, normal mind again as-
sumes its duty for a longer or shorter period of
368
Journal of Iowa State Medical Society
[September, 1922
time. The dread symptoms, howexer, as is well
known, never fail to appear.
If careful observation is kept, these patients
show many clinical fluctuations. Some one has
said, that “the course of paresis is not steady, but
wave-like, each rise and fall carrying the sufferer
one more step nearer the end.”
There has evidently been a grave mistake in the
teaching of the anatomy of women. Some an-
atomist has blundered, or the student has studied
anatomy with the skeleton standing on its head;
for instead of locating the brain of the woman,
like that of man, away up in the highest pinnacle
of the human structure, it has been slipped down,
so to speak, to about the lowest part of the
woman’s anatomy, called the pelvis.
When a nervous woman that is subject to men-
tal disturbances, comes to one of these misin-
formed doctors for treatment, he at once looks
for the trouble in the pelvic department. If it
is found that there is some pelvic trouble, even
though slight, it is concluded at once that this is
the seat of the trouble; and if it be one or more
of the generative organs in question, it must be
sacrificed, and forthwith an operation is recom-
mended, thus many times depriving the woman
of the sacred rights she has, of being called a
woman. Tinkering with the pelvic organs often
intensifies and aggravates the nerve trouble,
causing a longer period for recovery, when a
much shorter period was needed; and sometimes
causing a hopeless mental derangement.
It is true that any part of the body that is out
of plumb or diseased, may tend to add to the ner-
vous trouble, but the dismembering does not, as
a rule, always restore the sick nerves to their
normal. Many mental and nervous cases come to
the hospital with a history of having had a pelvic
operation, which was unsuccessful, leaving the
patient more nervous and more hysterical than
before the operation. Therefore, all surgical
measures in mental and nervous cases, in regard
to the female generative organs, should be under-
taken with great caution and conservation.
It has been stated that heredity plays a great
part in the human race. If anyone doubts this,
let him study the records of the state institutions,
and he will find that childhood and youth help
increase the population of the various places. In
the state hospitals for the nervous and insane,
one will find a number under the age of twenty-
years. Do you wonder why they are here ? Some
will say IVIother Nature has been remiss, has been
unkind — others, that home surroundings and in-
fluences are to blame. The real reason is hered-
ity. Nearby, or far down along the chain of
ancestry there has been a flaw, a weakened link.
This may be due to alcoholism, to epilepsy, or va-
rious other things.
We have been told that “the sins of the fathers
are visited on the sons unto the third and fourth
generation,” so it may be that a great uncle, or a
great-great-grandfather may have been an alco-
holic ; a great-aunt, an epileptic, and so on. The
results, though far-fetched, has been for them a
weakened nervous constitution. This has been
their legacy at birth. Some suffering from an
unstable, weakened nervous system, can be
helped, some made well for a time, but cannot be
kept well, unless they could be separated from
their inheritance.
Robert Rentou, in one of his late works, terms
that a child’s Magna Charta is the birthright to
be born physically healthy and bright; the birth-
right to be happy, to be useful citizens, and
healthy parents. These born with weakened ner-
vous systems have not received this Magna
Charta. Since the study of eugenics is well under
headway, and there has been legislation on the
manufacture and use of alcoholic liquors, and
the sale and use of narcotics, has been limited and
the cases of venereal diseases must be reported to
the state board of health, and with other reform-
atory measures, it is to be hoped that those born
in the next few centuries will be marked by less
hereditary trouble, by strong nervous constitu-
tions, and that the life stream will be kept free
from boulders and breakers.
The Good Book says, “The poor you have with
you always.” Well might it have added, that in
the state institutions, the aged you have always
with you; for the hospitals for the mental and
nervous are virtually becoming the home of the
aged.
In the Clarinda State Hospital, with a popula-
tion of 1200, there is about 500, or 24 per cent of
the population, ranging in age from sixty to
ninety years ; forty have been admitted in the
last year. The reason why there are so many
more aged in the hospital than formerly, is not
entirely due to the fact that senile dementia is
increasing, but because people are taking more
advantage of the hospitals.
A visit to the hospital will reveal to you many
white-haired and hoary heads, many bent forms
and wrinkled faces. This picture needs no ex-
planation. Time has been the master hand. A
close examination finds the skin dry, yellow, and
wrinkled; the muscles shrunken, the eyes dulled
of lustre, sight is impaired, the voice has lost its
crispness ; there is a high degree of hardening or
calcareous degeneration of the arterial system.
VoL. XII, No. 91
Journal of Iowa State Medical Society
369
This marks the retrogression of the organs of the
body, in which the brain has an equal share. It
becomes shrunken, atrophy of the cells of convo-
lution, and the gross lesion, softening, are often
present.
No class of patients brings out one’s sympathy
as much, or more, than the class before you. They
are often individuals who have worked hard,
early and late the greater part of their lives, so
that when they reached a certain age, they might
have their coffers sufficiently filled, that they
might spend the remainder of their days in peace,
quiet and comfort, and if parents, that their chil-
dren might enjoy some of the luxuries that the
world affords. But when they reached this pe-
riod of life, they were not mentally able to enjoy
their hardearned comforts, and some not per-
mitted to remain in the home. They have burned
their candle at both ends — they have burned it
late into the night, so to speak. They have worn
both mentally and physically while they wrought,
and nature has not kept apace, has not kept up
repairs. Sooner than aware, age has crept upon
them. A glance at their stooped shoulders, their
silvered hair, and their wrinkled faces, tells you
that senility is before you. Were you to try to
converse with them, you would be aware that de-
mentia is also present.
The word “senility” brings a mental picture
of one who is fast approaching the three-score-
and-ten milestone of life, whose physical strength
has begun to wane. With senile dementia, or
mental death, the picture changes somewhat, and
you have before you, one who in addition to phy-
sical enfeeblement, has the pathological condition
of the brain, either in the cells or other component
tissues, that marks mental weakness and decay,
from which there is no restoration, no hope, for
improvement, no help no relief but that of death.
Nothing can be done for them other than care
for their immediate wants, to nurse them, to help
smooth their pillow, and to ease them on their
downward path. This should be done in the
home by loving hearts and kindly hands, instead
of being done away from home, and by strangers.
It is right and proper for those who cannot,
and are not financially able to give their aged
ones proper care in the home, to take advantage
of hospital care ; but it does seem heartless, since
no help can be given, for those who are amply
able to have their enfeebled aged ones properly
cared for in the home, to put them in hospitals,
where nothing familiar greets their faded eyes.
Those who are influential in such matters, be-
fore sending the very old, feeble, and demented
from their homes, should weigh the matter well,
as to whether or not it will be the best for the
patient ; for it usually shortens their days, and
increases the mortality of the institutions.
Those that are most agitated, either wear out
in a short time, or pass into a more deepened de-
mented state, due to the progress of retrogression.
Oftentimes the restlessness, resistiveness and de-
sire to wander is simply the beginning of the end.
.So bear with the aged insane for a while
longer, — in the home if possible, and do not hurry
them away to the already too crowded institu-
tions, where they take up the time of the nurses,
that should be given to those patients that promise
a recover)", or improvement. I do not say this
with any malice toward the aged — for I love
them, and think, of all people, they no doubt are
the most deserving.
Therefore, I make the simple plea that the
senile demented in mind and feeble in body, be
permitted, if possible, to spend their few remain-
ing days in their homes. Since the number sent
to the hospital is gradually increasing, the state
no doubt will be prevailed upon some time in the
future, to provide an institution for those af-
flicted with senile dementia.
The path of the psychiatrist is not always
strewn with thorns and sharp pebbles. There are
many flowers along the way. One can under-
stand what a great pleasure it is to watch a mind
that for months has been disorganized, deranged,
and benighted, as it were, gradually becoming ar-
ranged, so that darkness will be turned into light,
delirium into clear thinking, so that things will be
seen and understood as they are, not as they seem.
The clouds are dispersed, the sun once more
shines brightly, and life once more takes on a
rosy hue.
If in this rambling, one thought has been ex-
pressed that will cause you to have more sympa-
thy for those mentally afflicted, and be the means
of your giving one kindly thought to the psy-
chiatrist and his work, the paper has served its
purpose.
370
Journal of Iowa State Medical Society
[September, 1922
NASAL HEADACHES*
Otis R. Wolfe, M.D., and E. L. Wahrer, M.D.,
Marshalltown
In presenting this paper, it is our intention to
omit discussion of suppurative sinus conditions.
We wish to dwell especially on the cases that
present themselves with a chain of symptoms,
particularly headache, in which no sign of sup-
puration is present ; that is, those cases that can-
not be diagnosed as sinusitis, per se.
Most of these cases, though, will have, a his-
tor}' of acute suppuration at some previous time.
This history of suppurative nasal condition is not
always elicited, however, as it is generally co-
incident with a coryza and usually subsides with
the coryza.
We wish to emphasize, however, that were it
not for certain anatomical conditions present
within the nose at the time of the corj'za and sup-
puration, that with the subsidence of these symp-
toms the affected tissues would in most cases re-
turn to normal.
In addition to the anatomical deviation from
normal there are certain exciting conditions, or
factors, that tend to incite, exaggerate, and pro-
long the coryza and nasal infection. These are
constitutional diseases with lowered vitality,
nephritis, and arteriosclerosis with increased
blood-pressure. Tobacco, alcohol, gases, and im-
proper ventilation are also exciting factors. Our
modern heating systems which extract so much
of the moisture from the air accounts for much
of the lowered vitality of the nasal mucous mem-
branes, and plays an important part as an ex-
citing factor in coryzas, and subsequent acute
exacerbations.
The bacteriological factor of course is present,
but it is difficult to say just how much it is re-
sponsible for these cases in which suppuration
does not exist, even though it may have been the
exciting cause. Eollowing a suppuration co-inci-
dent with coryza, there may be a destruction of
glands of the mucosa, and a beginning hyper-
plasia and chronic inflammation of the mucous
membranes.
The lining mucous membrane of the sinus is
composed of ciliated epithelium with a motion
wave toward the sinus ostium. The inflammation
and hyperplasia interferes with this, not only for
the emptying of pus, but also for its normal se-
cretion. The hyperplasia of bone is but a step
further in the process.
•Presented before the Seventieth Annual Session. Iowa State
Medical Society, Des Moines, Iowa, May 11, 12, 13, 1921,
Section Ophthalmology, Otology and Rhino-Laryngology.
Headaches of nasal origin are much more fre-
quent than generally supposed. Statistics taken
from our records show that about 35 per cent of
the headaches that have come under our observa-
tion had a nasal factor that could be demon-
strated. These cases present themselves to the
general practitioner as migraine, neuralgia, in-
herited headaches, “stomach” headaches, neu-
ritis of the head and upper extremities, and in a
great many instances are attributed to eye trou-
ble.
Accompanying these symptoms are many ner-
vous and intellectual disturbances. The patient
often complains of lapses of memory, mental
torpor, impaired ability to concentrate on busi-
ness affairs, and a marked aversion to mental
work. The patient is very apt to be labeled a
neurasthenic, and in fact often becomes one. He
goes from one occulist to another to have his
glasses changed, hoping each time that relief may
be obtained. In many instances the patient seeks
and often finds relief in the different headache
remedies, which is a dangerous practice.
We wish to lay special emphasis on the fact
that the headache or pain may bear no relation in
location to the site of the lesion.
We have found in going over our cases and
consulting the literature that these cases of nasal
headaches of non-suppurative sinusitis fall nat-
urally into four groups: (1) vacuum sinusitis,
(2) headaches due to nasal pressure with end
nerve irritation due to contact, or retained secre-
tions that are non-suppurative, (3) nasal gan-
glion neuroses and (4) hyperplastic sphenoiditis.
The vacuum frontal headache is one of the
most difficult to diagnose and differentiate. The
symptoms are those of asthenopia. The patient
has a low grade, constant headache, which is
made worse by use of the eyes. There is no pus
in the nose, no severe pain, and frequently no
nasal symptoms at all. In fact all the patient’s
symptoms are ocular. This condition is due to
the fact that after closure of the sinus, the air is
partly absorbed, and the resulting negative pres-
sure makes the sinus walls very sensitive. The
floor of the sinus is its thinnest wall, and to it is
attached the pulley of the superior oblique. Any
use of the eyes pulls on the sensitive sinus floor,
and causes a dull headache with disinclination to
use of the eyes.
Inherited headaches, so-called, are frequently
of the vacuum frontal type. However, what the
patient has inherited is not a headache, but a nar-
row nose which has become complicated by a hy-
perplastic change in either the soft parts or the
bone. Dr. Ewing was the first to recognize the
VoL. XII, No. 9]
Journal of Iowa State Medical Society
371
vacuum frontal headache and to describe the
symptoms which are, briefly; inability to use the
eyes for close work because of the headache
which is produced, and which is not relieved by
glasses or eye treatment. It is accompanied by
a tender point in the upper, inner angle of the
orbit. (Ewing’s sign.) This sign is almost
constant.
The frequency with which these headaches oc-
cur in the morning is explained in the following
manner. During the night the mucosa of struc-
tures composing the drainage passages become
hyperemic and swollen to such an extent that the
air changes in it are entirely suspended. As a
consequence the blood absorbs the oxygen con-
tained therein, the volume of carbon dioxid given
off being in disproportion. This results in a neg-
ative pressure in the sinus, causing pain until the
sinus is again aerated. x\ir changes in the sinus
during respiration should be in direct ratio to that
in the nares.
The anatomical changes tending to produce a
vacuum frontal sinusitis will be found to group
themselves under three distinct classes. They
are; (1) enlargement of the tubercle of the
septum, with a narrow passage, (2) noses that
appear normal until the removal of the middle
turbinate demonstrates that the hiatus semi-
lunaris is closed by apposition of the uncinate pro-
cess and the bulla, (3) edema and hypertrophy
of the middle turbinate and the vault of the mid-
dle meatus following a coryza. The mechanism
by which closure is produced is a combination of
unfavorable anatomical conditions such as a nar-
row nose presents, plus hyperplastic changes in
the soft parts and bone.
Nasal symptoms are frequently absent and un-
less there is some obstruction to breathing, the
patient attributes his symptoms to eye strain in a
large number of cases.
On inspection, the tubercle of the septum will
usually be found in contact with or close apposi-
tion to the middle turbinate. Spurs near the
floor of the septum or enlargement of the in-
ferior turbinate may obstruct breathing, and pre-
vent proper aeration of the sinuses, but are other-
wise a negligible factor.
The nose should be carefully shrunken with
cocaine and adrenalin and followed by suction to
see if pus secretion exists. This very frequently
relieves the headache, provided the middle turbin-
ate is not too large or firm or has not undergone
a bony hyperplasia. Alkaline sprays and astring-
ents relieve such patients until another attack of
coryza. Plenty of fresh air, physical exercise
and attention to diet tends to lower congestion.
In most cases, however, re-occurring attacks with
increased severity makes it expedient to resort to
surgery.
In the majority of cases, removal of the an-
terior one-half of the middle turbinate suffices.
Drainage is established and aeration facilitated.
We do a previous sub-mucous resection usually
at the same time, which not only gives more space
in the nose, but enables the operator to thoroughly
perform his turbinectomy on the side of the con-
vexity. It cannot be satisfactorily done in a
large number of cases without this previous sub-
mucous resection. Failure to relieve many of
these cases can in our mind be traced back to this
point.
Some of these patients obtain relief, however,
in later life, due to the atrophy of mucous mem-
brane that naturally occurs. The sinus ostia,
which have been obstructed, and mucous mem-
brane which has been in apposition are freed by
the atrophy, provided the hyperplasia is chiefly
of the soft parts.
This accounts for histories of headaches we
often obtain that would undoubtedly come under
this heading i. e., either the vacuum or pressure
type. These patients tell you, “I had a catarrh
when I was younger, but it is much better now.”
An associated error of refraction not suffi-
cient in itself to cause marked headache, or other
symptoms, may when associated with some nasal
irritation, cause considerable of either.
To differentiate, refraction under cyclopegia
should be performed. If the accommodation is
active it should be used in older people. Astig-
matism against the rule, and the phorias especially
hyperphoria and exaphoria are frequently asso-
ciated with these frontal and anterior ethmoid
involvements. Frequently they show improve-
ment when the nasal condition is relieved.
Adhesions of the middle turbinate to the con-
vexity of the septum may and frequently do
cause end nerve irritation. This may be jointly
to blame with the vacuum condition. This com-
bination alone is very frequently the cause of
headaches. In our experience it is the one most
frequently met with. It may cause a vacuum
condition in the ethmoids or a retention of the
secretion, causing a pressure headache.
When this condition is met with, it should be
thoroughly cleared up at the time of the opera-
tion. If sufficient space cannot be obtained be-
tween the posterior septum and the posterior part
of the middle turbinate by removing the posterior
part of the septum with our preliminary sub
mucous resection, we should remove the re-
mainder of the middle turbinate. It is at this
372
Journal of Iowa State Medical Society
[September, 1922
point of the operation that our thorough sub-
mucous resection will be most advantageous in
determining and dealing with adhesions.
An operation otherwise perfect, may fail to
relieve the patient if adhesions and apposition of
the posterior part of the middle turbinate and the
septum exist.
Headaches due to nasal pressure are sub-
divided into two classes: (1) those causing end
nerve irritation, and (2) retained secretions that
are non-suppurative.
We feel that one of the most frequent causes
of headaches of nasal origin is to be found in
cases in which there are adhesions between the
septum and middle turbinate, or pressure of the
middle turbinate on the septum. These patients
complain of pain which varies from a dull un-
ending ache to an intense neuralgic pain. These
symptoms are supplemented with a condition of
marked neurasthenia in most cases. The patient
is unable to concentrate on his work for any
length of time, he is alternately excited or mo-
rose and there is a marked disinclination to any
form of work requiring mental effort. This type
of case is extremely amenable to operative treat-
ment. A sub mucous resection with removal of
the offending turbinate or in many instances, a
turbinectomy will give complete relief.
There is another type of headache, in which a
large middle turbinate will be found impinging
on the septum, but without sufficient force to
cause end nerve irritation. It is sufficient, how-
ever, to block the natural drainage of the maxil-
lary ostium, and the frontal ethmoid region.
Shrinkage of the nose with subsequent suction
will demonstrate a large amount of clear mucous,
non-suppurative in character. Insufficient drain-
age has allowed this secretion to accumulate,
causing a low grade headache. In most cases,
removal of the middle turbinate will suffice to
correct this condition, although a submucous re-
section is also indicated in a certain number of
cases.
Nasal Ganglion Neuroses — Sluder ably de-
scribes this condition and dwells in detail on many
symptoms due to lesions affecting the nasal gan-
glion. He says this ganglion is frequently lo-
cated very superficially in the lateral wall of the
nose. By actual measurements, Meckel’s gan-
glion frequently lies as close as 2 mm. to the
nasal mucous membrane, or may be as deep as 7
mm. This accounts for the relief of various
symptoms accomplished by removal of the entire
or posterior part of the middle turbinate. This
also shows why adhesions between the turbinate
and septum, or pressure of the septum on the
turbinate will cause many obscure neuralgias,
headaches, and reflex symptoms.
Sluder cites many instances in which cures
have been effected of all sorts of obscure nerve
irritations of the ganglion. Relief may be af-
forded to many of these conditions by use of as-
tringents applied to the region of the spheno-
palatine foramen.
Cocainization of the nasal ganglion has pro-
duced some unusual phenomena, some of which
are hard to explain. Ewing discovered that the
pain of glaucoma could be stopped by anesthetiz-
ing the nasal ganglion, and Miller and Luedde
proved that injection of the ganglion lowered the
intra ocular tension of glaucoma, but that the
effect was transitory.
Sluder cites numerous cases in which the pain
of photophobia, glaucoma, iritis, corneal ulcers,
and phlyctenular keratitis may be stopped by co-
cainizing the nasal ganglion. Also, in many of
these cases the cotfl'se of the disease was greatly
shortened, and immediate improvement noted.
This is undoubtedly due to the effect of the co-
cainization on the sympathetic nervous system,
causing a nerve blocking of the sympathetic fi-
bres from the nasal ganglion.
It is rather difficult, as a rule, to make a posi-
tive differential diagnosis between lesions of the
nasal ganglion, and those of sphenoidal origin. It
is fairly safe to say, however, that (1) cocainiza-
tion of the nasal ganglion stops the pain of a le-
sion in the ganglion proper, but (2) does not stop
the pain created by the more central lesion of the
nerve trunks secondary to sphenoidal inflamma-
tion. However, (3) intra-sphenoidal application
of cocaine will stop the pain of sphenoidal le-
sions.
Treatment of these cases is not always satis-
factory, and considerable patience must be exer-
cised in dealing with them. Applications of
astringents to the region of the spheno-palatine
foramen, or injection of the ganglion itself, give
as a rule fair results.
Hyperplastic S phenoiditis- — We are of the
opinion that non-suppurative involvement of the
sphenoid and post-ethmoid regions following
coryza and infections is very frequent, but rather
difficult to diagnose. Man)' of these cases are
perhaps the result of old posterior nasal infec-
tions, dating in many instances from infected
adenoids and tonsils of childhood.
Dean and others have demonstrated the fre-
quency of sphenoid sinusitis of childhood. Dean
attributes it chiefly to infected adenoids, stating
that 80 per cent of these cases are cured by re-
moval of tonsils and adenoids alone. These facts
VoL. XII, No. 9]
Journal of Iowa State Medical Society
373
are especially valuable to consider as a factor in
explaining the hyperplasia of mucosa and bone in
the sphenoid and posterior ethmoid region.
While the cases we speak of may, or may not,
present pus at the time of examination, still there
is usually a history of pus in the nose. Severe
attacks of coryza, or infected adenoids, may be
the only history obtained. The hyperplasia re-
sulting from the inflammation may involve both
the soft part and the bone. The mucous mem-
brane becomes thickened and in many instances
sclerotic.
Such a condition can easily therefore cause
marked symptoms, in a.s much as the sphenoid
sinus is in such intimate relation with so many
nerve trunks. This is especially true if the sinus
is large, because the nerve canals and foramina
are then only separated from the sinus by a com-
paratively thin wall of bone. The hyperplasia can
therefore exert pressure on the nerve trunk in its
canal or even narrow the canals and foramina.
The result would be headaches, neuralgias and
other symptoms along the distribution of the par-
ticular nerve involved. This condition is the un-
derlying cause of many of the re-occurring head-
aches in people who are otherwise healthy.
These headaches also have been characterized
as migraine, inherited or idiopathic headaches.
The headaches felt in the lower half of the head,
or as patients often say, “they feel as if they
have a chunk of lead in the center of their head,
or at the bases of the brain,’’ are sphenoid in
origin. This condition is exaggerated if com-
bined with retention of secretion, as we believe
quite often occurs.
Constitutional diseases, straining at stool,
coryza, etc., all exaggerate the symptoms.
The sphenoid sinus is usually easily accessi-
ble for inspection and treatment after preliminary
removal of the middle turbinate. If the septum
is markedly deviated, it should be corrected by a
sub-mucous resection. This is especially true if
the deviation is well back in the septum.
W'e believe in these cases the posterior septum
should be removed back to the rostrum of the
sphenoid. This has been especially efficacious in
our experience.
After watching .some of these cases secure re-
lief in which there was apparently no suppura-
tion, no pressure of turbinates on the septum, and
no occlusion of the sphenoidal ostium, we have
come to the conclusion that the bony septum was
causing increased intracranial pressure.
We believe hyperplasia of bone occurs very
frequently in the posterior .septum. Sluder and
his colaborer W'right have proved conclusively
that hyperplasia of bone occurs in the sphenoid.
Following his line of thought and theorizing
further, it seems I'easonable that if sufficient hy-
perplasia of bone occurs in the sphenoid to crowd
bony canals and cause symptoms, it would also
crowd the posterior septum, causing increased
pressure there and vice versa. If the hyperplasia
were most marked in the septum we would also
have increased pressure on the ethmoid, and an
increase of intra-cranial pressure.
We cannot otherwise explain why the removal
of this posterior part of the septum gives the
relief it sometimes does. We cannot explain why
some of the posterior septums are as thick as
they are, except as a hyperplasia of bone follow-
ing inflammation and hyperemia. This condition
is especially marked at the junction of the vomar
and the perpendicular plate.
We believe that this hyperplasia combined with
the increased ossification of advancing age in
bones of the skull, can cause increased pressure
on the structures adjacent to the sphenoid and
ethmoid, with headache as the chief symptom.
On the other hand, some of these patients, later
in life, get a cessation of symptoms and an ap-
parent cure. Sluder attributes this to a rarefying
osteitis, an involution of the hyperplastic changes.
After the septum is straightened and the mid-
dle turbinate removed, the sphenoid can be
treated. Astringents may be applied to the os-
tium, or solutions be injected into it, which is
usually sufficient. It can be opened by any of
the approved methods with good results.
Conclusions
That nasal conditions without suppuration,
causing headaches and other symptoms, are very
frequent. Migraine, neuralgias and ocular symp-
toms that do not respond to eye treatment can be
frequently traced to the nose, and relief given.
That adhesions between or apposition of the
middle turbinate and septum is the most frequent
factor in the causation of sym])toms.
That hyperplasia of bone in the ]>osterior sep-
tum occurs and may cause symptoms by an in-
creased pressure on adjacent bony structures.
If after reasonable time, permanent relief is
not afforded by non-surgical treatment, the sur-
geon is justified in operating. The operation of
choice is the one that will afford the greatest de-
gree of aeration and drainage in the ujiper and
posterior nose, with the least sacrifice of mucous
membrane.
Case Reports
Case 1. Mr. W. R. F., aged thirty-nine, former
minister, gave it tip on account of inability to use
eyes. Almost constant frontal headache, exagger-
374
Journal of Iowa State Medical Society
[September, 1922
ated by reading or coryza. Pain in back of neck, and
shoulders, marked aversion to mental work. Always
had some catarrh. Many refractions. Glasses partly
relieved headache. Nose examined but never sug-
gested as a cause of headache. Examination: astig-
matism against the rule with one-half degree of hy-
perphoria. Corrected with some relief. Nose shows
very thick septum, marked thickening of mucous
membrane and bone, especially in middle turbinate
region. Both middle turbinates in close apposition
to septum. Fairly good breathing space on floor of
nose. Neither middle turbinate shrinks well. Diag-
nosis: vaccuum frontal sinusitis and end nerve irri-
tation. Operation showed unusuallj' thick cartilage
and bone in upper anterior septum. Did a sub-
mucous resection, anterior one-half both middle tur-
binates removed, with complete relief.
Case 2. Mr. D. \V., aged twenty-two, farmer.
Constant frontal headache, worse toward evening.
Nose never bothered, but catches cold easily. No
obstruction to breathing. Had nose injured when a
child. Examination: slight occlusion of right nostril,
both inferior turbinates large, septum straight, but
thickened posteriorly, anterior one-half of both mid-
dle turbinates adhered to septum, right markedly so.
Diagnosis: End nerve irritation. Removed anterior
one-half of both middle turbinates, and crushed and
fractured inferior turbinates. Complete relief.
Case 4. Mrs. O., aged sixty-four, housewife. Very
anemic, general examination negative, except trace
of albumin. Always had more or less headache, but
last few weeks had become very severe. Patient in
bed most of the time. Had very severe pains in
back of head and shoulder, running down arms, but
worse in forehead and behind eyes. Use of eyes and
light exaggerated condition. Always had some ca-
tarrh. No obstruction to breathing. Examination:
nose shows no stenosis, septum somewhat thickened.
Inferior turbinates normal, middle turbinates in ap-
position to septum on both sides. Culture from nose
showed streptococcus. X-ray showed large sinuses al-
though patient was small woman. Frontals shows
suspicion of pus. Operation under local. Did com-
plete ethmoid exenteration on both sides, following
turbinectomy.
Found both middle turbinates tightly adhered to
septum. Both middle turbinates had large ethmoid
cells composing most of the turbinate, containing
mucous but no pus. Frontal sinus easih- probed but
showed no pus. Opened both sphenoids. Found
them large, containing mucous, but no pus.
Patient weak, concluded operation, expecting to
open frontals at another time. Patient made rapid
improvement. Headaches disappeared. Had slight
secretion, not of a pus nature, but culture showed
streptococci. Irrigated, used suction. Patient made
complete recovery with no return of symptoms in
eight months. Gained ten pounds in weight, and
general health has made marked improvement. We
cite this case believing that while a streptococcus
infection had been present, that the infection was not
causing the symptoms. We believe that it was
caused by hyperplasia of bone and soft parts, exist-
ing in the middle turbinates and ethmoid, causing
pressure from retained secretion, and end nerve irri-
tation, and irritation of the nasal ganglion.
HYPER AND HYPO-THYROIDISM*
John W. Shuman, ]\I.D., F.A.C.P., Sioux City
Permit me to present for our consideration to-
night ttvo clinical pictures : The one of a woman
who is a “hyper;” the other of a man who is a
“hypo.” The answer being disturbed function of
the thyroid gland. No apolog}' is made for either
the style or brevity of this manuscript. In the
discussion let us confine ovtrselves to diagnosis
and treatment and leave out the etiology and
pathology- of the diseased thyroid.
Picture No. 1
Is of an individual rather ordinary in appear-
ance, habits, etc., until the age of thirty or thirty-
five and then suddenly takes a spurt ahead and
makes a success or at least an attempt at suc-
cess. Success meaning “the prosperous tennina-
tion of an enterprise.” Such an individual is not
uncommon and is most noticeable in the female
of the human species. I have in mind a mother
of two children who until the age of thirty-four
was truly domestic, suddenly developed the de-
sire to “emancipate” herself, with the result that
she turned her children out to a boarding school,
her house work to servants, her husband to his
clubs and took up other than household duties
and succeeded in becoming the president of a
well known local woman’s club, a number one
golfer, etc., etc. The question logically follows :
where did she get this new enthusiasm, restless-
ness, “pep,” etc., which changed herl^ The stim-
ulation came from her thyroid gland, for at the
age of thirty-four she developed an appreciable
increase in the size of the thyroid gland and grad-
uallv lost fifteen jiounds in weight, had moderate
exopthalmos and attacks of tachycardia, she also
experienced insomnia. This was a case of mod-
erate hvperthyroidism. She has now gone over
a period of six years with seemingly no marked
changes other than just described. It is probable
that there will be a retrogression of her symptoms
at or following her menopause.
Picture No. 2
Is of an individual who is an up and doing
sort, who had been noted for putting big things
‘Presented before the Fortnightly Meeting of the Woodbury
County Medical Society, Sioux City. October 12, 1921.
VoL. XII, No.9]
Journal of Iowa State Medical Society
375
over in a big way up to the age of forty- five and
then came to a sudden halt. This abrupt halt
was noted by the man himself, but more so by his
family. He slept from ten to twelve hours a
night, went to his office late, could not make de-
cisions readily, his business became a bore, he
gained twenty pounds in weight within one year
and a half and he had an abnormal appetite. The
proof in this case that there was a disturbed in-
hibited thyroid function was the clearance of the
above symptoms following his taking one-fifth
grain of thyroid extract three times daily, for the
physical and mental abnormalities disappeared
following the medication over a period of three
months, and returned to a degree when the thy-
roid extract was omitted.
Individuals with too much thyroid secretion
are quick, nervous, restless, undernourished and
poor sleepers. Examples in women are found in
public positions. In men we find them in the club
rooms in the evenings rather than at home with
their families.
Individuals with too little thyroid secretion are
slow mentally and physically and without ambi-
tion. Both conditions depend directly upon the
degree of hyper and hypo-thyroid function. The
backward school child, the village fat boy, the fat
lady of the circus are common examples of hypo-
thyroidism and can often be materially aided by
proper organotherapy. It is quite true that often
these cases are suffering from poly-glandular dis-
turbances (pituitary, thyroid, sex glands, etc.).
The treatment of the hyper-thyroid is embodied
in one sentence; reduce the amount of thyroidin
to normal. To do this has been the aim of all
therapeutists. Medically inhibitory remedies
chief of which are arsenic, morphine and bromide
have in some instances secured desired results,
but in most instances have been of no value.
Thyroidectin and ovarian extract have also been
administered. The x-ray alone or in conjunction
with the above remedies has been of some value
in a number of instances. The x-ray in doses
the thyroid secreting cells. Much care should be
used in x-ray treatment. Surgically, resection
of the gland has been most advantageous in the
largest number of instances in cutting down the
dose of thyroidin. Surgery has met with nu-
merous difficulties; the chief of which being the
correct amount of the gland to remove. We have
all seen myxedema resulting, in thyroidectized in-
dividuals, quieting of symptoms over a period of
time, and then a lighting up of the hyperthyroid-
ism following. We must make the comment here
that the greatest fault we find with surgical treat-
ment of hyperthyroidism is the fear of removing
too much of the gland. If this fear be eradicated
more lasting cures of hyperthyroidism will be
effected.
PHYSICIANS WHO LOCATED IN IOWA
IN THE PERIOD BETWEEN 1850-1860
D. S. Eairchild, M.D., F.A.C.S., Clinton
John C. Hughes, M.D., Keokuk
Dr. John C. Hughes, was bom in Washington
county, Pennsylvania, April 1, 1921, and died in
Keokuk August 10, 1881. Dr. Hughes repre-
sented the type of strong men who came to Iowa
at a relatively early day.
It is a curious and interesting fact that Iowa
grew into a state without a definite plan, and ap-
parently made the best of things as they came
along. It is unfortunate perhaps that Iowa de-
veloped without much regard to tl^e experience
of older states, but rather prided herself on her
independence of precedent and often adopted
methods tried out and abandoned by other states,
frequently no doubt at a great expense of time
and resources. Happily, here and there, strong
men came forward with a vision to the future to
direct the ignorant and selfish who gave little
thought to the days to come.
It does not appear that Dr. Hughes was par-
ticularl)' active in political affairs, but devoted
his energies to developing and co-ordinating the
activities of his profession which he so ably rep-
resented, and to welfare service of the city in
which he lived. During his lifetime Keokuk was
the recognized medical center of Iowa.
In 1850 the Keokuk College of Physicians and
Surgeons was located in Keokuk after migrating
from La Porte, Indiana, in 1846 where it was
born, to Madison, Wisconsin, 1847; Rock Island,
1848; Davenport, 1849; to Keokuk its permanent
home, 1850.
Dr. Hughes studied medicine in Baltimore,
Maryland, with Dr. Joseph Perkins and gradu-
ated from the University of Marjdand in 1845.
He began practice in Mt. Vernon, Ohio. In 1850,
he came to Keokuk and was elected demonstrator
of anatomy in the medical school which was soon
to become recognized as the medical department
of the Iowa State University. In 1851 he was
made professor of anatomy. In 1852 was elected
dean of the faculty and in 1853 professor of sur-
gery which position he held to the time of his
death in 1881.
The duties of his office as dean involved a
wide range of activities. A medical college sixty
or seventy years ago was in a measure a business
376
Journal of Iowa State Medical Society
[September, 1922
institution. It had no endowment fund, and was
generally owned by a small group of men who
sought to provide a “drawing faculty’’ to attract
students and provide money in various ways ; stu-
dent fees were mainly relied upon to pay ex-
penses and provide a return on the money in-
vested.
Dr. Hughes was a man of much tact and was
fortunate in establishing friendly relations with
the profession of Iowa and neighboring states.
The requirements for entrance and for gradua-
tion were not high and the success of the school
was measured more by the number of students
and the personnel of its faculty than by its effi-
ciency in preparing young men for scientific med-
ical practice.
Dr. Hughes was appointed surgeon general of
the state by Governor Kirkwood at the outbreak
of the Civil War ; a position he held until its close.
He was chairman of the Board of Aledical Exam-
iners and did much to aid the governor in organ-
izing the medical service of the Iowa regiments.
During this service, he was in charge of the
Army Hospital at Keokuk.
Dr. Hughes was elected president of the Iowa
States IMedical Society in 1856 and again in 1866,
he and Dr. Thomas Sivester were the only men
elected twice to that office. Dr. Hughes was
made chairman of the section on surgery at the
Richmond meeting of the American IMedical As-
sociation and was a charter member of the Amer-
ican Surgical Association.
Dr. Hughes was a skillful surgeon and an able
diagnostician. He was also a man of affairs and
enjoyed an enviable reputation and influence
throughout the state. He was a member of the
Iowa branch of the Christian Sanitary Associa-
tion and rendered valuable service as such to the
soldiers at the front and in the hospitals during
the Civil W ar.
He was editor of the first medical journal pub-
lished in Iowa under the name of the Iowa ]\Iedi-
cal Chirurgical Journal, and later changed to the
Iowa Medical Journal. Altogether, Dr. Hughes
was easily the surgeon standing first in the history
of Iowa.
Dr. Henry Clay Bullis
Dr. Henry Clay Bullis of Decorah was born in
Clinton county, X. Y., X'ovember 14, 1830, died
in Decorah, September 7, 1897. Dr. Bullis was
a man of varied experience and activities. From
the age of nineteen to twenty-one he taught
school in winter and worked on his father’s farm
in summer. When he had reached his majority
he added to his previous labors the study of med-
icine. After six years of teaching, farming and
studying medicine he attended two courses of
medical lectures at the Vermount Medical Col-
lege at Woodstock and graduated in the summer
of 1854. In 1887 he received an additional de-
gree from Jefferson Medical College, Philadel-
phia. Dr. Bullis came to Decorah October 28,
1854, and for one month taught school when he
entered upon the practice of his profession, which
he followed for more than forty years. Decorah
was then a small village in an unsettled country
save here and there a farmer who was locating a
home. Dr. Bullis received but a limited educa-
tion yet with energy, accumulated experience and
exceptional executive ability, he was fitted to ex-
tend his activities beyond the routine of an early
country practitioner. He became active in local
affairs and in 1865 he was appointed United
States examining surgeon for pensions which po-
sition he held until 1876 when he resigned to ac-
cept an appointment as a member of the Sioux
commission. Earlier or in 1856, he was ap-
pointed by Judge Reed, commissioner for the sale
of intoxicating liquors which position he held for
one year when this office was abolished. A
little later the office of county superintendent
was created when Dr. Bullis was elected in April,
1858 to fill it, he being the first incumbent, for a
period of two years. In October, 1863, he was
elected county supervisor serving two years, the
last year as chairman of the board. In the fall of
1865 Dr. Bullis was elected by the republican
party to represent Winneshiek county in the
state senate, at the end of a four year term he was
re-elected. While in the senate he served as
chairman of the committee on claims, and also as
chairman of the State University committee. He
devoted much time to the interests of the uni-
versity and was a moving spirit in building it on
a solid foundation and served for eighteen years
as regent, declining re-election. In the middle of
his second term as state senator and while serv-
ing as president, he was nominated and elected
lieutenant governor by the republican party. It
was in August, 1876, that President Grant ap-
pointed Dr. Bullis a member of the Sioux In-
dian Commission which was created for the pur-
pose of purchasing the Black Hills Reservation,
one of the important facts in the political history
of the country in which Dr. Bullis had an active
part. In 1878 he was appointed by President
Grant, special United States Indian Agent whicii
position he resigned after nine month service. In
April, 1883, he was appointed special agent of
the General Land Office but resigned after eight
months service. Both these offices involved trav-
eling and exposure beyond his strength hence his
VoL. XII, No. 9]
Journal of Iowa State Medical Society
377
resignation. In 1880-81 and in 1889-90 he served
as mayor of Decorah. In the latter term he re-
signed to accept the appointment as postmaster
which position he held four years. Was presi-
dent of the Iowa State ]\Iedical Society in 1876.
Dr. Bullis was married September 11, 1854 to
Miss Laura A. Adams of Champlain, New York,
who died in 1861. In June, 1863, he married
Miss Harriette B. Adams, a sister of the first
wife. Few physicians have had a wider or more
varied experiences than Dr. Bullis. The writer
has a clear recollection of Dr. Bullis. He was a
man of attractive personal appearance ; a man of
little more than average height, rather slender but
erect and active ; dressed in the conventional
clothes of the professional man of that day, a
ready and fluent speaker, and was admired by
the younger men of the profession whose ideas
were not disturbed by the revelations of the bac-
teriologists.
Dr. J. W. Smith
Dr. J. W. Smith was born in Franklin, New
York. Graduated from the medical department
of Yale University in 1856. Located in Charles
City, Iowa, March, 1857. Dr. Smith became a
member of the Iowa State IMedical Society in
1872 and w^as one of the most active members in
the work of the society. He was a recognized
surgeon in northern Iowa and appears to have
been the first in this state to perform a supra-
vaginal hysterectomy. In May, 1872, Dr. Smith
removed a fibroid tumor of the uterus by “gas-
tratomy,” including the uterus, which weighed
fifteen pounds. “This operation was not advised
but was done at the urgent .solicitation of the suf-
fering but heroic woman aged thirty-two. Death
occurred on the sixth day.” We have a vivid
recollection of Dr. Smith who was known in the
State Society as “irrepressible Smith” for the
reason no doubt, that no paper passed without
“.Smith of Floyd” taking part in the discussion.
In the American ]\Iedical Association he was
known as “Smith of Iowa” for the same reason.
He was rigid in his temperance views and lost
no opportunity to bring prohibition into the dis-
cussions of the society.
Dr. Charles M'. Davis
Dr. Davis was bom in Troy, Ohio, January 4,
1823, and died in Indianola July 20, 1881. Dr.
Davis graduated A. B., Wabash College, Craw-
fordville, Indiana, in 1848, and M.D. from Rush
Medical College, 1853. After practicing at Car-
lisle for three years, removed to Indianola in 1856
where he practiced until the time of his death.
On October 15, 1862, Dr. Davis was mustered
into the United States service as surgeon of the
Thirty- fourth Iowa Infantry. After active ser-
vice under General Sherman, he resigned No-
vember 25, 1863, and resumed practice in In-
dianola taking an active part in professional mat-
ters.
In 1869, Dr. Davis became a member of the
Iowa State Medical Society and in 1876, a mem-
ber of the American ^Medical Association.
ACTION FOR SERVICES RENDERED NON-
RESIDENT PATIENT
The Supreme Court of Iowa, in affirming a judg-
ment in favor of the plaintiff, in an action on an
account, says that the defendant, formerly a resident
of Iowa, became a resident of South Dakota in the
spring of 1919. In the fall of that year, she returned
to Iowa, where the plaintiff, a physician, attended her
during confinement. It was to recover for those ser-
vices that this action was brought. What the defense
relied on -was the statute of limitations of South Da-
kota, which is six years on an open account. The
contention was that, as that period had elapsed be-
tween the rendition of the services and the com-
mencement of this action, it was barred under the
provisions of the South Dakota statute. This posi-
tion, however, was untenable. The section of the
Iowa code says that when a cause of action has been
fully barred by the laws of any country where the
defendant has previously resided, such bar shall be
the same defense in Iowa as though it had arisen
there, but its further plain provision does not apply
to causes of action arising within the State of Iowa.
The services in question were rendered by the plain-
till, and the cause of action arose in Iowa. It was
therefore, immaterial that the action could not be
maintained in South Dakota because of the bar of
the statute of that state. — Journal of A. M. A., April
8, 1922.
TREATMENT OF ANGIOMA BY RADIUM
M. Robineau reported to the Paris Surgical So-
ciety, two observations on parotid angionomas in
very young infants who were cured by radium. The
patients returned after a considerable time in perfect
condition. The advantage of radium over other
methods of treatment is the advantage of being ap-
plied to all regions with the greatest facility. Its
employment is painless and leaves no scar and
avoids (in the case of parotid angiomas) injury to the
facial nerve. Its action is more efficacious when
the lesion is of recent origin. Also M. Degrais, who
irridated M. Robineau’s patients, recommends the
commencement of the treatment from the date of
birth. — (La Presse Medicale.)
378
Journal of Iowa State Medical Society
[September, 1922
®f)t Journal of tljc
3otoa ^tate jilcJjical ^ocieti*
D. S. Fairchild, Editor Clinton, Iowa
Publication Committee
D. S. Fairchild -Clinton, Iowa
W. L. Bierring Des Moines, Iowa
C. P . Howard Iowa City, Iowa
Trustees
Des Moines, Iowa
Clarinda, Iowa
Waterloo, Iowa
SUBSCRIPTION $2.75 PER YEAR
Books for review and society notes, to Dr. D. S.
Fairchild, Clinton. All applications and contracts
for advertising to Dr. T. B. Throckmorton, Des
Moines.
Office of Publication, Des Moines, Iowa
Vol. XII September 15, 1922 No. 9
PERKIN’S TRACTORS
In these days of wonderful and mysterious
methods of treatment, we have forgotten that in
the latter part of the eighteenth century and the
early part of the nineteenth, a method of treat-
ment was in vogue equal in strangeness to any-
thing we have now and attracted the attention of
great and small then, as now. The advantage in
the study of medical history lends a feeling of
comfort when we reflect on the waywardness of
the human mind in accepting strange methods of
cure of disease based upon physical evidence and
occult philosophical reasoning.
At a recent meeting of the Boston History
Club, Dr. Walter R. Steiner of Hartford, read a
paper on Dr. Elisha Perkins and his Metallic
Tractors. The great popularity of Perkin’s Trac-
tors from 1796 to 1803 and the fact that they
were forgotten in 1811 leads us to reproduce a
part of Dr. Steiner’s paper.
“Dr.- Elisha Perkins was born in Norwich,
Connecticut, on January 16, 1741. His medical
education came largely from his father Dr.
Joseph Perkins, a well-known and respected phy-
sician of that vicinity. He settled in Plainfield
for the practice of his profession and became
prominent and popular, giving largely to the sup-
port of the academy and taking many of the stu-
dents into his own house to live. It is said that
his family at times numbered fifty. During the
Revolution he was surgeon to the Eighth Infan-
try. In his practice he had noted the influence
of metallic substances on nerves and muscles, and
had observed the contraction of muscles under
the knife. This led to his discovery in 1796, of
his famous metallic tractors. These consisted of
two rods of metal, about three inches long, shaped
like horseshoe nails, with the legend “Perkin’s
Patent Tractors’’ stamped on them. One of these
was made of copper, zinc, and a little gold; the
other consisted of iron, silver and supposedly
platinum. The pair cost about a shilling to manu-
facture and sold for two guineas. “To Perkinize’’
was to draw the instruments alternately across the
painful part, or from the painful part to the ex-
tremity. It was, however, stated that this “does
not always relieve headache due to the excessive
use of strong drink.”
The discovery was reported at a meeting of the
Connecticut Medical Society, but was apparently
received with some doubt. However, Dr. Perkins
went with his tractors to Philadelphia and took
that city by storm. Congress was sitting at the
time and prominent legislators became his pa-
tients. Washington was reported to have pur-
chased a set, and so popular did they become that
people sold horses and carriages to buy them.
One speculative individual sold his plantation and
took the pay in tractors. In February, 1796, a
patent was taken out. The Connecticut Medical
Society, refusing to honor its own prophet, con-
demned the practice at this time, and the follow-
ing year expelled the discoverer from the body.
In 1799 he died in New York of typhoid, a dis-
ease he had gone there to cure with his tractors.
Benjamin, a son of the inventor, and a gradu-
ate of Yale, went to London in 1795 and opened
an office to introduc.e the tractor. In applying
for a patent in England he explained that it was
“generally believed that they act on the galvanic
principle.” This, however, was but one of sev-
eral explanations of their action. Among many
cited in his book as users of the tractors were
nine members of the clerical profession, six of
them doctors of divinity. One person, less favor-
ably impressed, wrote : “If they have ever re-
lieved pain I have found them useful also in pick-
ing walnuts.” Several books appeared extolling
the virtues of the tractors ; one was published in
Copenhagen (Denmark had fallen before the
tractors) and translated into German and English.
Fifty cases formed the basis of this Danish re-
port.
The tractors, it was stated, must be applied
three times daily for one-half an hour. They
were not effective in venereal or scrofulous dis-
eases. .\s proof that imagination had no part in
the cures attributed to the tractors it was pointed
J. W. COKENOWER.
T. E. Powers
W. B. Small
VoL. XII, No. 9]
Journal of Iowa State Medical Society
379
out that they were equally effective on infants, in
epileptic fits, and on dumb animals, where no
imagination could exist. Mr. John Grant of
Leighton, Buzzard of Bedfordshire, found the
metallic tractors “equally useful on the brute ani-
mal as on the human subject, and I think they are
more active on the horse than on those which
chew the cud as sheep, cows, etc.”
The first Perkinian Institution was opened in
1804 in Frith street, Soho square, London. Many
others followed. One poem of lasting fame re-
sulted from the tractors. Supposed to be a
satire on Perkinism, it was probably written at
the instigation of Benjamin Perkins by a Ver-
mont inventor in London and is in reality a bitter
satire against the Royal College of Physicians.
“The Modern Philosopher, or Terrible Tractor-
ations ! A Poetical Petition x\gainst Galvanizing
Trumpery and the Perkinistic Institution in Four
Cantos, Most Respectfully x\ddressed to the
Royal College of Physicians by Christopher
Caustic, M.D., LL.D., A.S.S., Fellow of the
Royal College of Physicians, Aberdeen, and Hon-
orary Member of no less than nineteen very
learned Societies.”
Benjamin Perkins left England in 1803 with ten
thousand pounds derived from the sale of tractors,
and established in New York in the bookselling
business. He died soon after at the age of thirty-
seven. By 1811 the tractors were almost forgot-
ten.”
MEDICAL CARE FOR DISABLED VETERANS
In the editorial column of the last issue of the
Journal, attention was called to the work of the
United .States Veterans’ Bureau, and it was
pointed out that fundamentally this work was of
a medical character and therefore should be of
primary interest to the medical profession. The
Ninth District of the U. S. Veterans’ Bureau in-
cludes the states of Missouri, Iowa, Kansas and
Nebraska, the headquarters of the District being
located at 6801 Delmar Blvd., St. Louis, Missouri.
Although the conduction of this work requires a
very large organization, certain phases of the
work can be considered separately for the pur-
pose of clearness. It should be understood that
the federal organization, the U. S. Veterans’ Bu-
reau, cannot accomplish to the highest degree its
purpose of maintaining the welfare of the dis-
abled veteran without the full co-operation of
other agencies interested in similar purposes.
Such co-operation is being freely given and there
has been, as an example of this, recently organ-
ized a District Rehabilitation Committee acting
with the X'ational Rehabilitation Committee of the
x\merican Legion, and this committee is now in-
vestigating the facilities for and conduct of re-
habilitation work in the 9th District of the U. S.
Veterans’ Bureau. The committee members and
their respective fields of inquiry are: Dr. Fred
W. Bailey, General Medical and Surgical ; Dr. H.
Unterberg, X’europsychiatric ; Dr. E. L. Opie, Tu-
berculosis; Prof. J. L. Van Ornum (Washington
University), Vocational Training Interests and
G. FI. W. Rauschkolb, Compensation and Insur-
ance. General members of the committee are:
Dan F. Steck, Iowa ; Wilber S. Metcalf, Kansas ;
Clinton Brome, Nebraska, and Dr. H. F. Parker,
Missouri. The chairman is H. D. iMcBride, of
St. Louis, and Robert Burkinan, St. Louis, is vice-
chairman.
At the present time we have available the pre-
liminary^ report of the committee, which aims to
render an exact and comprehensive report of the
conditions existing in the Ninth District regard-
ing the medical treatment afforded veterans and
the facilities available for hospitalization and
clinic treatment.
The committee finds that there is at present
but one government owned hospital in the Ninth
District, that being the U. S. Veterans’ Hospital
No. 57 at Knoxville, Iowa, which has a capacity
of 170 beds and is used wholly for the care of
veterans with psychoses. This institution was
formerly a state inebriate asylum.
There are four hospitals which are leased out-
right by the government, as follows: U. S. Vet-
erans’ Hospital X"o. 35, at St. Louis. This was
formerly an almshouse and the building and fa-
cilities are declared by the committee to be inade-
quate for the proper medical treatment of any
type of case. Its capacity is 650 beds and all
types of cases are at present housed in it, includ-
ing medical, surgical, tuberculosis and neuropsy-
chiatric. U. S. Veterans’ Hospital No. 67, at
Kansas City, Missouri. This was formerly a
general hospital with capacity of 130 beds and has
good facilities for medical and surgical cases and
for the observation of suspected tuberculosis. U.
S. Veterans’ Hospital No. 75, at Colfax, Iowa.
This was formerly a resort hotel with capacity of
200 beds. Facilities are only fair for medical and
surgical cases. The building is a fire trap and the
facilities are not in line with the requirements of
modern ideas of hospital treatment. The National
Military Home, Kansas, as the name indicates, is
a home for aged, disabled volunteer soldiers, but
arrangement has been made for 200 beds for the
use of the U. S. Veterans’ Bureau. The medical
facilities and personnel at this institution do not
380
Journal of Iowa State Medical Society
[September, 1922
warrant the hospitalization of patients in need of
active medical treatment.
All other hospital facilities are provided by
contract with existing institutions, the govern-
ment turning its disabled veteran patients over
to the regular personnel of these institutions,
with no direct supervision of the patients. The
following are a few of the hospitals now under
contract with the government in the Ninth Dis-
trict ;
For general medical and surgical pufposes there
are the Iowa Lutheran Hospital, Des IMoines,
Iowa ; the Mercy Hospital, Iowa City, Iowa ;
M’esley Hospital, Wichita, Kansas ; Lincoln San-
atorium, Lincoln, Nebraska; Swedish Hospital,
Omaha, Nebraska. For tuberculosis cases there
are the State Sanatorium, Oakdale, Iowa; State
Sanatorium, Norton, Kansas; Jasper County
Hospital, ^^'ebb City, Missouri ; IMt. St. Rose
Sanatorium, St. Louis, Missouri ; State Sana-
torium, Mt. Vernon, Missouri. For neuropsy-
chiatric cases there are the Cherokee State Hos-
pital, Cherokee, Iowa ; Independence State Hos-
pital, Independence, Iowa; Topeka State Hos-
pital, Topeka, Kansas; Punton Sanatorium, Kan-
sas City, Missouri; State Hospital No. 1, Fulton,
Missouri ; State Hospital, No. 2, St. Joseph, Mis-
souri; State Hospital No. 3, Nevada, Missouri;
State Hospital No. 4, Farmington, Missouri; St.
Louis City Sanatorium, St. Louis, Missouri ; Lin-
coln State Hospital, Lincoln, Nebraska; Still-
Hilldreth Sanatorium, IMacon, Missouri.
The committee finds that the total bed capacity
for the Ninth District may be divided as follows :
Government owned, 172; government leased,
1,176; contract, 319.
Later reports to be issued on the work of this
committee will concern the adequacy of the fa-
cilities mentioned and will make recommenda-
tions for changes which seem advisable. Such
recommendations will be referred to the National
Rehabilitation Committee of the American Legion
and to the manager of the Ninth District U. S.
^^eterans’ Bureau for action.
The Journal of the American IMedical Associa-
tion for ]\Iay 27 gives a percentage list for states
receiving the Journal which does not appear to
throw any particular light upon the intelligence
of the doctors of the different states. Iowa, for
instance, has a uniform paid up membership of
2330 members and 1972 copies of the Journal A.
M. A. or 56 per cent; Kansas has 50 per cent;
Illinois 64 per cent ; Indiana 45 per cent ; Mis-
souri 43 per cent; Minnesota 70 per cent; Ne-
hra.ska 57 per cent; Ohio 49 per cent; North Da-
kota 67 per cent ; IMinnesota the largest per cent,
70, and New Jersey’ next largest, 67 per cent;
Kentucky the smallest, 31 per cent; New York
55 per cent; Pennsylvania 60 per cent; Wisconsin
66 per cent.
Whether the thoroughness of local organiza-
tion has any influence we do not know, but it is
possible, for instance; LTah has 64 per cent and
Iowa 56 per cent; Kentucky 31 per cent, and Ari-
zona 65 per cent.
PERSONAL
Dr. James Taggart Priestley of Des Moines
celebrated his seventieth birthday and fifty years
of practice, July 19, 1922. Dr. Priestley was born
in Northumberland, Pennsylvania, July 19, 1852.
His great grandfather was Joseph Priestley, who
discovered “pure dephlogisted air,” later named
“oxygen” by French chemists. Joseph Priestley
was born in England in 1733, came to America in
1794 and died in Northumberland, Pennsylvania,
in 1804. He was an intimate friend of Benjamin
Franklin who urged him to locate in Philadelphia.
He was offered the chair of chemistry in the Uni-
versity of Pennsylvania, but preferred the quiet
life of a small town where he established a labora-
torjL Joseph Priestley was a minister and ac-
cepted the position of pastor of a small Unitarian
Church. Dr. James Taggart Priestley’s father
was a veteran of the Mexican War.
Scientific study and the practice of medicine
had an attraction for the Priestley family. Sir
William O. Priestley, a member of the family,
was a celebrated English obstetrician.
Following Dr. James Taggart Priestley was his
son Dr. Crayke Priestley, a young man of great
promise, who died early in his professional career,
and the two grandsons are now attending the
medical school of the University of Pennsylvania.
Dr. Janies Taggart Priestley located in Des
IMoines in 1876 and devoted himself to internal
medicine. At that time there were but few
specialists and in our country, medicine and sur-
gery were joined, but in a few years, by a pro-
cess of election in centers of population, men be-
came physicians or surgeons. Dr. Priestley be-
lieving there was a wider field in internal medi-
cine, elected the latter and consistently adhered to
his choice which brought him honor and distinc-
tion. He once stated to the writer that he had
sustained at one time or another, the relation of
physician or consultant to every Supreme Court
Justice of Iowa, which he held a distinguished ap-
preciation, a sentiment we fully concurred in.
Dr. Priestlei' now lays aside the duties of active
VoL. XII, No. 91
Journal of Iowa State Medical Society
381
practice with a feeling that he has passed through
the dangers which beset a physician, for a period
of half a century with a clean record, and met all
the conditions of friendly and unfriendly criti-
cism with absolute safety.
CHIROPRACTORS
The Journal of the Indiana State Medical As-
sociation informs us that the chiropractors’
Schools are so numerous in Fort Wayne that it is
difficult to keep track’ of them, and that the chir-
opractic signs out-number the signs of all real
doctors put together. We are assured, however,
that there has been no falling off in the practice
of real doctors. It appears that the strife among
the chiropractors in securing adjustment cases is
liable to disrupt the busiriess and thus settle the
question.
The editor comments on the important question
of medical education in Great Britain and finds a
way out for the British profession;
The British Medical Journal, in launching a cam-
paign to better the personnel of the medical profes-
sion, makes the statement that “No one should think
of entering this profession who is unprepared to
spend $75,000 on his medical education.’’ Is it pos-
sible that England has not heard of chiropractic for
the cure of all diseases and ailments from cancer to
chicken-pox, the science of which cult can be learned
in from three to six months, at a cost not to exceed
$100! Why spend $75,000! England indeed is “be-
hind the times” if she still believes in long medical
courses covering physiology, anatomy, bacteriology,
histology, pathology, etc., etc., when such knowledge
is entirely superfluous and all that is necessary is a
little exercise and training of the fingers to “manip-
ulate” the vertebrae for the cure of any and all dis-
eased conditions! Someone should advise the Brit-
ish Medical Journal of its terrible error in making
such a statement.
HOMEOPATHY IN STATE UNIVERSITIES
The Iowa Homeopathic Journal, January num-
ber, discusses editorially the unfortunate state of
homeopathic medicine. The writer (G. R.), loses
sight of the fact that the doctrines of Simila
Similabus Curator and Contrara Contraris Cur-
anter are obsolete and that the two great schools
of medicine have joined in the common purpo.se
of cultivating medicine on scientific principles.
The action of the Board of Regents of the State
University of Michigan in amalgamating the two
schools of medicine, is another victory for the alleo-
path against the homeopath. Slowly but surely
might is conquering over right. First it was the
State of Minnesota, where the forces of the A. M. A,
working through the legislature and tiie Board of
Regents caused the death of the homeopathic school
in Minnesota. The second battle was fought in
Iowa. Here the little band of homeopaths fought
the enemy for years, both before the legislators and
before the board of education. Finally a specious
plea for harmony influenced the leaders of the two
forces to compromise the matter. The legislature
with the consent of both parties enacted a law es-
tablishing a Department of Homeopathic Materia
Medica and Therapeutics in the College of Medicine
in the State University. The understanding was
that this department should have all the rights and
privileges of any other department in the College of
Medicine.
But when the test was made, the attendance of the
students in the Department of Homeopathic Medi-
cine and Therapeutics was made optional. A condi-
tion which did not exist in any other department of
the College of Medicine. After attempting to main-
tain the department, the head resigned; resignation
taking effect June 30, 1921. The resignation, how-
ever, was sent the board of education before the leg-
islature met in 1921, in order to give the board of
education an opportunity to have the law changed if
the board saw fit. No change, however, was made,
and the law still stands “authorizing and directing”
the board of education to maintain the chair. Not-
withstanding this fact, neither a head for the depart-
ment or assistants of any kind have been provided
by the board of education. There are points of sim-
ilarity in the methods and means of securing their
end in the three states above mentioned. The chief
argument in each state was economy. Dr. Cope-
land, before the meeting in Ann Arbor, Michigan,
showed how ridiculous this claim was by showing
that thousands of dollars annually were spent teach-
ing such subjects as “Old Norse, Xenophon’s Anaba-
sis, the Olympian and Pythian odes, and similar
courses.” He then pictured the benefit for humanity
of teaching homeopathic medicine rather than the
above named subjects. What the result of the com-
mittee to work out the details of the amalgamation
may be, one thing is certain, viz., that it is not the
intention of the old school of medicine to have the
principles and practice of homeopathy taught in the
University of Michigan or any other university. An-
other method of the enemy of homeopathy is to con-
centrate his efforts on one point at a time. He first
perverted the intent of the legislature in the State of
Missouri; he then did the work rapidly, but effi-
ciently in the State of Minnesota; he then began work
in the State of Iowa, meanwhile directing a side at-
tack on us in the State of California; finishing his
work in the State of Iowa, he then concentrated upon
Michigan. Since the work was completed in Michi-
gan, which was during its last legislative session, he
has already begun in the State of Ohio, in whith
state he has been preparing his forces since our col-
lege was established in the Ohio University. While
the defenses of the State of Ohio are much stronger
382
than were those in any of the other states, on the
other hand, the enemy has eliminated our forces at
the other points and is now in position to use every
means at his command to secure victory in Ohio.
Every lover of homeopathy, of truth and justice,
should unite in an effort to assist the standard bear-
ers in the State of Ohio.
TRI-STATE MEDICAL ASSOCIATION
The physicians of Iowa are most cordially invited
to attend the annual assembly of the Tri-State Dis-
trict Medical Association which is to be held at
Peoria, Illinois, October 30, 31, November 1 and 2.
The entire time of the assembly, outside of a few
social features will be taken up with scientific ad-
dresses, essays and diagnostic clinics. The diag-
nostic clinics are a very important part of the as-
sembly. They will start every morning at 7 o’clock
and continue throughout the forenoon. The after-
noon and evening sessions will be taken up with lit-
erary contributions.
The territory covered by this organization in-
cludes the entire states of Illinois, Iowa and Wiscon-
sin and districts of surrounding states. The at-
tendance promises to be very large, therefore, you
are requested to make your arrangements for at-
tending the assembly as early as possible.
Synopsis of the program of the annual assembly of
the Tri-State District Medical Association held at
Peoria, Illinois, October 30, 31, November 1 and 2:
FIRST DAY
, Monday, October 30, 1922, 7 a. m.
1. Diagnostic Clinic (Surgical). Preference, ab-
dominal cases. Dr. William Seaman Bainbridge, New
York, N. Y.
2. Diagnostic Clinic (Medical). Preference, car-
diac, mediastinal, pleural or intrapulmonic disease.
Dr. Charles F. Hoover, Prof, of Medicine; Western
Reserve University, School of Medicine, Cleveland,
Ohio.
3. Diagnostic Clinic (Surgical). Dr. Emmett Rix-
ford. Prof, of Surgery, Leland Stanford Junior Uni-
versitj% School of Medicine, San Francisco, Califor-
nia.
Intermission
4. Diagnostic Clinic (Medical). Preference, pep-
tic ulcer, anemia, or goiter cases. Dr. John A.
Witherspoon, Prof, of Medicine, Vanderbilt Univer-
sity, Medical Department, Nashville, Tennessee.
5. Diagnostic Clinic (Surgical). Preference, ab-
dominal cases. Dr. John B. Deaver,* Prof, of Sur-
gery, University of Pennsylvania, School of Medi-
cine, Philadelphia, Pennsylvania.
Afternoon Session — 1 p. m.
6. (a) Diagnostic Clinics (Nervous Diseases).
One epileptic patient, one brain tumor, one spinal
cord tumor, one trifacial neuralgia, one spina bifida,
one cerebral arteriosclerosis, one pernicious anemia.
[September, 1922
Dr. Alfred W. Adson, Dr. Henr}’ W. Woltman, Mayo
Clinic, Rochester, Minnesota.
(b) Diagnostic Clinic (Nervous Diseases). Pref-
erence, brain tumor, spinal cord tumor, fracture of
the spine, old fracture of skull with epilepsy. Dr.
Charles A. Elsberg, Prof. Clinical Surgery, Univer-
sity and Bellevue Hospital, Medical College, New
York, N. Y.
7. “Injuries of the Cornea.” Dr. Alfred N. Mur-
ray, Chicago, Illinois.
8. Diagnosis and Treatment of Epilepsy. Dr.
Edward M. Williams, Sioux City, Iowa.
9. (Wisconsin man).
10. “Respiratory Excursions of the Thorax.” Dr.
Charles F. Hoover, Prof, of Medicine, Western Re-
serve University, School of Medicine, Cleveland,
Ohio.
Intermission
11. “Mechanics of Production of Fractures and
Methods of Treatment derived therefrom.” (Black-
board drawings, lantern slides.) Dr. Emmett Rix-
ford. Prof, of Surgery, Leland Stanford Junior Uni-
versity, School of Medicine, San Francisco, Cali-
fornia.
12. “The Distribution and Delivery of Medical
Service.” Dr. Frank E. Sampson, Creston, Iowa.
13. “Tumors of the Breast; A study of 255 cases.
(Lantern slides.) Dr. William D. Haggard, Prof, of
Surgery, Vanderbilt University, School of Medicine,
Nashville, Tennessee.
Evening Session— 7 p. m.
14. “The Treatment of Deformities of the Upper
Extremities.” Dr. Arthur Steindler, Prof. Ortho-
pedic Surgery, University of Iowa, School of Medi-
cine, Iowa City, Iowa.
15. “Dacryocystitis — Its Cure by a Combined In-
tra and Extra-Nasal Operation.” Dr. J. Sheldon
Clark, Freeport, Illinois.
16. “Ectopic Gestation with Report of Cases.”
Dr. Thomas W. Nuzum, Janesville, Wisconsin.
Intermission
17. “The Sequelae of Some Unusual Traumata.”
Dr. Oliver J. Fay, Des Moines, Iowa.
18. “The Management of Maternity.” Dr. Will-
iam D. Chapman, Secretary Illinois State Medical
Society, Silvis, Illinois.
19. “Drug Addiction and The Harrison Narcotic
Law.” Dr. Ernest S. Bishop, Clinical Prof, of
Medicine, New York Polyclinic Medical School, New
York, N. Y.
SECOND DAY
Tuesday, October 31, 1922, 7 a. m.
1. Diagnostic Clinic (Nose and Throat). Prefer-
ence, nose and throat cases. Dr. Greenfield Sluder,
Prof, of Laryngology and Rhinology, Washington
University, School of Medicine, St. Louis, Missouri.
2. Diagnostic Clinic (Pediatrics). Preference, pe-
diatrics, Harvard University, School of Medicine,
Boston, Massachusetts.
3. Diagnostic Clinic (Surgical). Dr. William D.
Journal of Iowa State Medical Society
VoL. XII, No. 9]
Journal of Iowa State Medical Society
383
Haggard, Prof, of Surgery, Vanderbilt University,
School of Medicine, Nashville, Tennessee.
Intermission
4. Diagnostic Clinic (Medical). Preference, chest
case (heart, lungs, or mediastinum) or a case of
fever. Dr. Lewis A. Conner, Prof, of Medicine,
Cornell University, School of Medicine, New York,
N. Y.
5. Diagnostic Clinic (Surgical). Dr. John M. T.
Finney, Prof, of Clinical Surgery, Johns Hopkins
University, Medical Department, Baltimore, Md.
Afternoon Session — 1 p. m.
6. “The Development of Brain and Spinal Cord
Surgery and its Significance for the Specialist and
for the General Practitioner.” Dr. Charles A. Els-
berg. Prof. Clinical Surgery, University and Bellevue
Hospital, Medical College, New York, N. Y.
7. “Medical Education, Past and Present.” Dr.
John A. Witherspoon, Prof, of Medicine, Vanderbilt
University, Medical Department, Nashville, Ten-
nessee.
8. “Better End Results in operations for gastric
and duodenal Ulcer.” Dr. John M. T. Finney, Prof,
of Clinical Surgery, Johns Hopkins University, Medi-
cal Department, Baltimore, Maryland.
9. “The Modern Conception of Acidosis.” Dr.
Julius Weingart, Des Moines, Iowa.
Intermission
10. (Wisconsin man.)
11. “Observations on Lobar Pneumonia.” Dr.
Francis G. Blake, Prof, of Medicine, Head of De-
partment of Medicine, Yale University, School of
Medicine, New Haven, Connecticut.
12. “Cholecystitis — A Typical Manifestation.” Dr.
August Frederic Jonas, Prof, of Surgery, University
of Nebraska, School of Medicine, Omaha, Nebraska.
13. “X-ray Diagnosis in Tuberculosis, Syphilis,
and Ostemyelitis of the Bones.” Dr. Robert W.
Lovett, Prof, of Orthopedic Surgery, Harvard Uni-
versity, School of Medicine, Boston, Mass.
Evening Session — 7 p. m.
14. “Chronic Fatigue Intoxication.” Dr. Edward
H. Ochsner, President-elect Illinois State Medical
Society, Chicago, Illinois.
15. Subject later. Dr. Walter L. Bierring, Des
Moines, Iowa.
16. (Wisconsin man.)
17. “The Control of Mandibular Pain Through
the Nasal (Sphenopalatine-Meckel’s) Ganglion; The
Control of Ear-ache through the Nasal (Spheno-
palatine-Meckel’s) Ganglion.” Dr. Greenfield Sluder,
Prof, of Laryngology and Rhinology, Washington
University, School of Medicine, St. Louis, Missouri.
Intermission
18. “Trifacial Neuralgia; its Symptoms, Diagnosis
and Treatment.” Dr. Alfred W. Adson, Mayo Clinic,
Rochester, Minnesota.
19. Subject later. Dr. Joseph A. Pettit, Prof, of
Surgery, North Pacific College, Portland, Oregon.
THIRD DAY
Wednesday, November 1, 1922, 7 a. m.
1. Diagnostic Clinic (Orthopedic). Preference,
orthopedic cases. Dr. Robert W. Lovett, Prof, of
Orthopedic Surgery, Harvard University, School of
Medicine, Boston, Massachusetts.
2. Diagnostic Clinic (Surgical). Preference, ab-
dominal cases. Dr. John H. Gibson, Prof, of Sur-
gery and Clinical Surgery, Jefferson Medical College,
Philadelphia, Pennsylvania.
3. Diagnostic Clinic (Medical). Preference, rheu-
matic and arteriosclerotic heart disease and show
cases with heart failure. Dr. Francis G. Blake, Prof,
of Medicine, Head of Department of Medicine, Yale
University, School of Medicine, New Haven, Con-
necticut.
Intermission
4. Diagnostic Clinic (Surgical). Dr. Alexander
Primrose, Dean and Prof. Clinical Surgery, Univer-
sity of Toronto, Faculty of Medicine, Toronto,
Canada.
5. Diagnostic Clinic (Surgical). Preference,
goiter and abdominal cases. Dr. George W. Crile,
Prof, of Surgery, Western Reserv'e University,
School of Medicine, Cleveland, Ohio.
Afternoon Session — 1 p. m.
6. “Gastric and Duodenal Ulcer.” Dr. John B.
Deaver, Prof, of Surgery, University of Pennsyl-
vania, School of Medicine, Philadelphia, Pennsyl-
vania.
7. “Malignant Tumors of the Breast.” Dr. Alex-
ander Primrose, Dean and Prof. Clinical Surgery,
University of Toronto, Faculty of Medicine, To-
ronto, Canada.
8. “The Diagnosis of Pericardial Effusion with
Special Reference to Physical Signs on the Posterior
Aspect of the Thorax.” Dr. Lewis A. Conner, Prof,
of Medicine, Cornell University, School of Medicine,
New York, N. Y.
9. “The Liver, Gall-bladder and Ducts.” (a) Re-
lation of the liver to the organism as a whole, (b)
Its significance in surgical operations and diagnosis,
(c) Possible new role of the liver. Dr. George W.
Crile, Prof, of Surgery, Western Reserve University,
School of Medicine, Cleveland, Ohio.
Intermission
10. “The Oedematous Cardiopath.” Dr. Joseph
M. Patton, Prof .of Clinical Medicine, University of
Illinois, School of Medicine, Chicago, Illinois.
11. “Chronic Indigestion in Children.” Dr. John
Lovett Morse, Prof. Emeritus of Pediatrics, Harvard
University, School of Medicine, Boston, Massachu-
setts.
12. “The Technique in Certain Forms of Osteo-
synthesis.” Dr. Einar Key, Riddaregatan 1, Stock-
holm, Sweden.
13. “Physiology and Abdominal Surgery.” Dr.
Allen B. Kanavel, Prof, of Surgery, Northwestern
L^niversity, School of Medicine, Chicago, Illinois.
384
Journal of Iowa State Medical Society
[September, 1922
Evening Session — 7 p. m.
14. “Surgical Judgment.” Dr. John H. Gibbon,
Prof, of Surgery and Clinical Surgery, Jefferson
Medical College, Philadelphia, Pennsylvania.
15. “Syphilis of the Nervous System.” Dr. Clar-
ence Van Epps, Iowa City, Iowa.
16. “A report on deep x-ray therapy of cancer as
practiced in Germany.” Dr. Roswell L. Pettit, Ot-
tawa, Illinois.
Intermission
17. Subject later. Dr. George V. I. Brown, Mil-
waukee, Wisconsin.
18. “Multiplex Pathology and the Cancer Prob-
lem.” Dr. William Seaman Bainbridge, New York,
New York.
Smoker
FOURTH DAY'
Thursday, November 2, 1922, 7 a. m.
1. Diagnostic Clinic (Medical). Preference, gas-
tric diseases with special reference to methods of
‘ examination. Dr. Charles F. Martin, Prof, of Medi-
cine, McGill University, Faculty of Medicine, Mon-
treal, Canada.
2. Diagnostic Clinic (Gynecological). Preference,
chronic diseases of the tubes or tubo-ovarian disease
or pelvic troubles. Dr. Walter W. Chipman, Prof,
of Obstetrics and Gynecology, University of McGill,
Faculty of Medicine, Montreal, Canada. Dr. John G.
Clark, Prof, of Gynecology, University of Pennsyl-
vania, School of Medicine, Philadelphia, Pennsyl-
vania.
3. Diagnostic Clinic (Medical). Preference, acute
or chronic types of any form of infectious arthritis;
nephritis cases. Dr. Frank Billings, Prof, of Medi-
cine, Rush Medical College, School of Medicine, Chi-
cago, Illinois.
Intermission
4. Diagnostic Clinic (Surgical). Dr. William J.
Mayo, Mayo Clinic, Rochester, Minnesota.
5. Diagnostic Clinic (Surgical). Dr. Allen B.
Kanavel, Prof, of Surgery, Northwestern University,
School of Medicine, Chicago, Illinois.
Afternoon Session — 1 p. m.
6. “Basic Factors in the Etiology and Therapeu-
tics of Uterine Hemorrhage.” Dr. John G. Clark,
Prof, of Gynecology, University of Pennsylvania,
School of Medicine, Philadelphia, Pennsylvania.
7. Subject later. Dr. John L. Y^ates, Milwaukee,
Wisconsin.
8. Subject later. Dr. William J. Mayo, Mayo
Clinic, Rochester, Minnesota.
9. “The Resourceful General Practitioner and
Modern Medicine.” Dr. Frank Billings, Prof, of
Medicine, Rush YIedical College, School of Medicine,
Chicago, Illinois.
Intermission
10. “The Inflammatory Pelvic Mass.” Dr. Wal-
ter W. Chipman, Prof, of Obstetrics and Gynecology,
University of McGill, Faculty of Medicine, Montreal,
Canada.
11. “Some Clinical Aspects of Myocardial Dis-
ease.” Dr. Charles F. Martin, Prof, of Medicine,
YIcGill University, Faculty of Medicine, Montreal,
Canada.
12. Subject later. Professor Theodor Tuffier,
Paris, France.
13. Subject later. Dr. Andrew Fullerton, Belfast,
Ireland.
Banquet — 7 p. m.
Presidents of State Societies.
Distinguished citizens of the United States.
Eminent members of the profession.
Conferring of honorary memberships.
The Tri-State District Medical Association, which
includes the territory covered by the entire states of
Iowa, Illinois and Wisconsin and districts of sur-
rounding states, extends to the medical profession a
hearty invitation to be present and participate in the
program at the annual assembly, which is to be held
at Peoria, Illinois, October 30, 31, November 1 and 2.
This association is purely a scientific body. It as-
sumes no political or legislative duties. The entire
time of the assembly, outside of a few social func-
tions, will be devoted to orations, essays, and diag-
nostic clinics.
A physician in order to become a member of this
association must be in good standing in the county
and state society in the territory in which he or she
resides.
You are cordially invited to bring your wife,
daughters or lady friend. Make your hotel reserva-
tion early (on account of the large attendance) by
communicating with Dr. Sidney Eaton, Secretary of
General Committees, Peoria, Illinois. If you have
any interesting cases for the clinics, let the Peoria
doctors know.
Signed,
Dr. Walter L. Bierring, Des Moines, Iowa.
Dr. Edward H. Ochsner, Chicago, Illinois.
Dr. George V. I. Brown, Milwaukee, Wisconsin.
Program Committee.
Dr. William B. Peck, Freeport, Illinois.
Managing Director.
Note: Dr. George M. Piersol, Prof, of Medicine
University of Pennsylvania, graduate School of Med-
icine, Philadelphia, Pennsylvania, will deliver an ad-
dress sometime during the meeting.
MEDICAL NEWS NOTES
Articles of incorporation for the new Council
Bluffs medical clinic were filed with County Re-
corder C. W. Atwood Monday, July 3. The clinic is
incorporated for $100,000, with nine local physicians
and surgeons as directors.
Doctors who compose the clinic are; Donald
Macrae, Jr., V. L. Treynor, M. A. Tinley, Mary
Tinley, M. E. O’Keefe, A. C. Johnson, W. E. Ash, C.
S. Erickson and C. A. Hill.
One hundred shares of stock at $1,000 a share are
VoL. XII, No. 91
JouK.wM. OF Iowa State Medical Society
385
to be sold while the indebtedness of the clinic is not
to exceed $10,000, unless by unanimous vote, accord-
ing to the articles of incorporation.
.'\nnual meeting of the stock holders will be held
on January .1 of each year, beginning in 1923. The
permit issued by Secretary of State Ramsay will not
expire for twenty years.
Plans for the clinic building at 532-534 First av-
enue, next to the Elks’ club, have been completed and
the contract is expected to be let within the next
few weeks. The building will be one of the most
modern and well equipped of any of its kind in the
Middle West.
The Iowa Pharmacists are making an active cam-
paign to secure a “fair representation in both the
senate and house of the state legislature.’’ Unless
they secure better results than did the medical pro-
fesion in the last legislature from members of their
own profession, they had better trust their legislative
interests to outsiders. — Editor.
PROTEST AGAINST THE PROPOSED TOOTH
BRUSH TARIFF
The Boston Medical and Surgical Journal offers
the following protest to a section of the new tariff
bill which proposes to make every American rich
and happy inasmuch as it will give the manufacturer
better profits and the purchaser cheaper goods.
“The New York City Department of Health has
issued a copy of a letter to the chairman of the
F’inance Committee, United States Senate, protest-
ing against the duty on tooth brushes. The state-
ment follows that there are less than a dozen manu-
facturers of tooth brushes in this country, and that
imported tooth brushes meet the needs of the vast
majority of our citizens in quality and price.
“Further, that the cost of illness which would fol-
low the omission of the use of the tooth brush would
far outweigh any income from the proposed tariff.
Such increase in cost would tend to nullify much of
the work done by health departments all over the
country, for a great deal of effort has been put forth
in instructing people regarding the necessity of using
the tooth brush.’’
PRESIDENT LOWELL ON HIGH COST OF
MEDICAL EDUCATION
President Lowell of Harvard University in his lat-
est annual report raises a question of much interest
to the medical profession and especially to medical
students. He calls the rise in the expense of medical
instruction “prodigious,” and adds that it has reached
a point where “we must ask ourselves how much can
properly be spent on medical education and how
much a community can afford to pay for it.” In
President Lowell’s opinion the problem is so serious
that he urges careful investigation, and suggests that
there be inquiry whether, by improved methods, the
equiinuents of the best medietd schools cannot be ap-
plied to broader field of educational service. He
would have some plan devised whereby students now
attending less highly de\eloped schools might be
enabled to benefit by the equipment of the schools
that are provided with the best. — Medical Record,
February 11, 1922.
It is with regret that the death is announced of
DR. ALEXANDER RIGHTER CRAIG
Secretary of the American Medical Association,
which occurred Saturday night, September 2, 1922, at
Port Deposit, Maryland
CLINIC POLK COUNTY MEDICAL SOCIETY
'I'he date of the Polk County Medical Society
Clinic has been changed to October 18, 19 and 20. A
tentative program will be mailed to the profession
of Iowa during the month.
MISSISSIPPI VALLEY MEDICAL ASS’N.
The Mississippi Valley Medical Association will
hold its forty-seventh annual meeting at Rochester,
Minnesota, Clctober 10, 11 and 12. An interesting
program of clinics, clinical demonstrations, and
formal papers to be presented by distinguished
guests has been arranged.
PERSONAL MENTION
Dr. Raymond L. Latchem has located in Sioux City
after finishing a service of over three years at the
Mayo Clinic and hopes to be able to establish a prac-
tice in urology.
Dr. John T. Hanna has located in practice at Bur-
lington where he will specialize in surgery and gyne-
cology.
Dr. H. C. Eschbach of Albia was operated upon at
the Presbyterian Hospital, Chicago, June 26.
Dr. Ruehl H. Sylvester resigned from directorship
of the Des Moines Health Center at the quarterly
meeting of the board of directors at Hotel Savery re-
cently. The resignation is to go into effect Septem-
ber 1.
Dr. T. R. Campbell received his appointment as
local surgeon for the Chicago and Northwestern at
Sioux Rapids. This position was formerly held by
the late Dr. E. E. Smith
Dr. William Seaman Bainbridge, Commander M. C.,
U. S. N. R. F., has been decorated by the French
government with the officer’s cross of the legion of
honor in recognition of his work with the allied ar-
mies at the various fronts and in the preparation of
a report on the medical and surgical developments of
the war.
Dr. Fred W. Bailey of Cedar Rapids will attend
the International Congress of Otology held in Paris
386
Journal of Iowa State Medical Society
[September, 1922
during the last week in July. His family will accom-
pany him and make a tour of England, Switzerland
and Italy, returning to the United States the last of
September.
HOSPITAL NOTES
On June 8 the staff of the Park Hospital in Mason
City, Iowa, entertained about fifty of their profes-
sional friends at a clinic, lasting all day.
While a number of interesting pathological condi-
tions were shown during operation, with demonstra-
tion of operative technique, most of the time was
given to demonstrations of diagnosis and medical and
surgical treatment.
Luncheon was served at the hospital at noon and
the visitors were guests of the hospital staff at a
banquet at the Eadmar hotel in the evening.
The program was as follows:
9 a. m. Dr. H. D. Fallows. Operative, 7 tonsil-
lectomies; demonstration, pansinusitis.
10 a. m. Dr. C. E. Dakin. Demonstration, frac-
tures; x-ray plates of children’s bones; 4 femurs, 2
tibias, 4 colles, 1 skull fracture, 2 humeri.
11 a. m. Dr. V. A. Farrell. Infant feeding, four
patients.
11a. m. Dr. N. C. Stam. Demonstrations; pyelitis,
irrigation of kidney pelvis, syphilis with salvarsan ad-
ministration.
12:30 lunch, for all. Basement of hospital.
1:30 p. m. Dr. L. R. Woodward. Internal Medi-
cine. The decompensated heart.
2:30 p. m. Dr. L. E. Newcomer. Demonstration:
Skin diseases, four patients; radium demonstration,
5 patients, epithelioma.
3:30 p. m. Dr. C. F. Starr. Blood Diseases of the
new born baby.
4:30 p. m. Dr. Geo. M. Crabb. Operative: Ap-
pendectomy, bilateral salpingitis. Demonstration:
Duodenal Ulcer and Gall-stones; Pelvic Cellulitis;
Second Degree Burn and Skin Graft.
6 p. m. Dinner — Eadmar Hotel.
OBITUARY
Dr. Harry L. Courtright, physician and surgeon,
died at Keokuk. He was taken ill while on a pleasure
trip in the West, and was operated on in Cheyenne,
Wyoming. He was brought home and had been in
a critical condition since that time.
Dr. Courtright was one of the prominent members
of the profession in Keokuk. He was a graduate of
the old Keokuk ^ledical College, and had practiced
for many years in Keokuk. He was kindly and sym-
pathetic in his nature, and of a cheerful, friendly dis-
position.
He practiced in Washington, Iowa, for a time and
returned to Keokuk, where he entered into partner-
ship with Dr. W. M. Hogle. They have had offices
in same building for several years.
Dr. Joseph Smith Lowell of Clinton died at Jane
Lamb Hospital, October 23, 1921, seventy-five years
of age.
Dr. Lowell was born in Hallowell, Maine, August
9, 18-46. When the Civil War broke out he enlisted
in Co. A, 16th Alaine Infantry and served during the
entire war.
Dr. Lowell graduated from the Hahnemann Col-
lege, Chicago, in 1878. Located in Clinton in 1881
where he practiced up to the time of his death, more
than thirty-five years. He was married at Fairfield,
Iowa, June 16, 1870 to Miss Alice King, who sur-
vives him.
Dr. John Allan Wyeth, who died of heart disease
in New York on May 28, 1922, in his seventy-eighth
year, was one of that band of Southerners who came
to New York to make a high reputation in medicine.
We have only to mention J. Marion Sims, Thomas
Addis Emmet, Nathan Bozeman and W. ^I. Polk to
recall some of the great ones.
Dr. Wyeth’s chief contribution to medicine was the
founding of the first post-graduate medical school in
the United States, the New York Polyclinic Medical
School and Hospital, which had its beginning in
1882. Dr. Wyeth was professor of surgery and presi-
dent of the faculty, in the school he had organized,
for the rest of his life.
The son of Judge Louis and Euphemia Allan
Wyeth, he was born in Marshall county, Alabama,
May 26, 1845. He attended the La Grange Military
Academy and entered the service of the Confederate
states as a private. For fifteen months he was a
prisoner at Camp Morton, Indiana; for much of the
war he was attached to Russell’s Fourth Alabama
Cavalry. Beginning the study of medicine in 1867, he
took his M.D. from the University of Louisville in
1869, the ad eundem degree of M.D. being conferred
on him by Bellevue Hospital Medical College, New
York in 1873. Later degrees given him were LL.D.,
University of Alabama, 1902, and the same degree
from the University of ^Maryland, 1909. — Boston Med-
ical and Surgical Journal, June 8, 1922.
MARRIAGES
Dr. W. V. Cone of Iowa City and Miss Avis Ellen
Wood were married at Muscatine, June 14, 1922.
Dr. Aura J. Miller of Burlington and Miss Mamie
Turnipseed of Iowa City were married June 29, 1922
at the Presbyterian Church, Iowa City.
Dr. Walter J. Connell and Miss Lucy H. Riggs of
Dubuque were married June 22, 1922.
Dr. F. L. Nelson and Miss Lorenza Ingraham of
Ottumwa were married at Ottumwa, June 28, 1922.
Dr. W. L. Downing and Miss Marion Klenk of Le
Mars were married at Buffalo, Minnesota, June 22,
1922.
Dr. W. P. Sperow of Carlisle and Miss Lola
Rodger of Iowa City were married in Newton, June
20, 1922.
Journal of Iowa State Medical Society
XV
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When writing to advertisers please mention The Journal of Iowa State Medical Society
XVI
Journal of Iowa State Medical Society
BOOK REVIEWS
PITFALLS
By A. J. Caffrey, IM.D., Instructor in Phy-
siology at Milwaukee Medical College from
1901 to 1910. Assistant Professor of Medi-
cine at Marquette University School of Med-
icine from 1913 to 1920. Boston Richard
Badger. The Gorlain Press.
The writing of this book is based on errors of ob-
servation in medical practice and the failure to ob-
serve certain apparent minor facts which if observed,
would point to certain controlling factors of essential
importance in avoiding pitfalls which come not only
to doctors but to others as well. In arriving at a
diagnosis, certain standard symptoms are observed,
a physical examination is made and laboratory tests
employed, all of which are coordinated in arriving
at a diagnosis. Notwithstanding ordinary care, er-
rors are made in evaluating the evidence presented.
The close observer of certain facts will not infre-
quently place an interpretation quite different from
the logical consideration of the clinical group of evi-
dence. The man of quick perceptions will see some-
thing that will give a turn to the evidence not per-
ceived by the routine observer which will save him
from the pitfalls daily witnessed. In acute diseases,
doctors are frequentl}- giving patients or friends
opinions which in a few days are found not to be true
to the indignation of interested persons and humilia-
tion to the doctor.
The book is written in a series of stories. There
are thirty chapters, each one is a story in which Dr.
X is the observer. We have all been witnesses at one
time or another of similar instances. Dr. X is a
good story teller, fortunately for us it relates to the
other fellow.
Dr. X one day tells his friend that he had been
discharged from a patient he had been called to that
morning, but would be called back in four days. He
saw a little girl five years old who was ailing slightly,
had a little fever and a little less inclined to play, but
otherwise well. The doctor examined that throat
and found some spots called Koplic’s spots, signifi-
cant of measles; advised that the child be put in bed
and kept quiet and given some simple medicines.
This did not quite suit the parents and they called
another doctor who found nothing and advised the
parents to let the child up and play out of doors. On
the fourth day the measles were out; then Dr. X
was called back, the second doctor discharged and
the parents indignant; the child came near dying
from pneumonia and the disease generally spread.
Here was the pitfall for the second doctor; it might
have been the pitfall for Dr. X, but Dr. X was a
shrewd observer and escaped, and presumedly gained
great credit.
The thirty stories relate to an equal variety of
experiences of interest to those who have escaped
the pitfalls, and of equal importance to those who
have fallen. The purpose of the writer of these
pleasant or unpleasant stories is to impress upon the
minds of us all the constant danger that surround
us and how easy it is to gain or lose credit by con-
stant watchfulness or lack of watchfulness. No one
entirely escapes, but some physicians are always fall-
ing into the pit and we know their fate. Some will
read this book and greatly profit by it.
INFANT FEEDING
By Clifford G. Grulee, M.D., L.L.D., As-
sociate Professor and Acting Head Depart-
ment of Pediatrics at Rush Medical College.
Fourth Edition. Thoroughly Revised, Oc-
tavo of 397 Pages. Illustrated. W. B.
Saunders Company, 1922. Cloth $4.50 Net.
Dr. Grulee who has gained the position of an
authority on infant feeding, brings his contribution
to date by offering a fourth edition of his work.
This is not a new book to the profession and we
need not do more than to announce the appearance
of a new edition. During the past few years, there
has been a definite advance in pediatrics in America
and a decline in Europe, as might be expected from
the unsettled conditions in Europe. Nevertheless
problems and experiences have arisen which may be
utilized in the future when affairs are better ad-
justed.
SURGICAL CLINICS OF NORTH AMERICA
February, 1922; \’olume 2; Number 1;
Philadelphia Number. W. B. Saunders Com-
pany. Price, Paper $12.00; Cloth $16.00 Net,
Per Clinic Year.
The Philadelphia Clinics are of unusual interest as
may readily be seen by referring to the men who
have contributed. Dr. John B. Deaver considers sev-
eral subjects. Duodenal Ulcer, Pylorectomy, Pos-
terior Gastrojejunostomy, with remarks on pathology
by Dr. Stanley P. Reimann. Followed by a clinic on
Adeno Carcinoma of the Breast, another. Recurrent
Cholecystitis, Operative Cholecystectomy, also Renal
Calculus. Dr. J. Chalmers Da Costa and Dr. Astley
P. C. Ashhurst present a series of cases. Dr. Charles
H. Frazier presents a contribution on Brain Tumor
in Relation to the Cerebrospinal Fluid and Ventri-
cles. Dr. Brooke M. Anspack presents several clin-
ical cases of special interest. Dr. George P. Muller
considers a number of important cases among which
may be noted a Case of Tuberculous Cervical Aden-
itis. Other contributors are Dr. Warren B. Davis,
who presents an interesting clinic. Harelip and Cleft
Palate, and Dr. P. G. Skillern, Jr., on Surgical Le-
sions of the Ulnar Nerve at the Elbow, which should
receive special consideration because of its import-
ance in relation to deformities and disabilities. This
Philadelphia number is of rare interest and value to
the general surgeon. We have not been able to
point out the details of the cases presented, only to
mention the general features of the work.
®f)e Jfoumal of tljc
3otoa ^tate JJlebital ^ottetp
VoL. XII
Des Moines, Iowa, October 15, 1922
No. 10
THE PROS AND CONS OF FOREIGN PRO-
TEIN INJECTIONS IN AFFECTIONS
OF THE EYE*
Jas. at Patton, M.D., F.A.C.S., Omaha
A close observer, writing some three thousand
odd years ago, noted that there was no new thing
under the sun, and this apparently applies to para-
specific therapy, for while I supposed that this
was a comparatively recent addition to our thera-
peutic armament, Peterson (Biological Therapy
p. 82), says “As a matter of fact, this form of
therapy, call it as we will, non-specific therapy,
protein therapy, etc., forms in all probability the
basis of the very earliest and most primitive
methods in practice that we encounter histor-
ically.” No doubt the stories heard in our pre-
medical days of remarkable cures of rheumatism
following an unusually interesting encounter with
a swarm of angr}^ bees; and how after recovery
from a severe attack of typhoid fever the patient
often felt better than he had for years, were sim-
ply an unconscious tribute to this very system of
therapy.
It is unnecessary to go into the history of the
development of modern sero-therapy. Suffice to
say that a careful consideration of the subject has
been of sufficient importance to occupy the care-
ful attention of our ablest research men and keen-
est clinicians. Vaughn (Protein Split Products,
p. 373) made a careful investigation of the ac-
tions of protein when introduced parenterally
and found that he was able, by varjdng the doses
and frequency of administration, to produce fe-
vers corresponding clinically to that of typhoid
and many other types. The cleavage of foreign
protein occurring in the process of parenteral
digestion of necessity liberates heat. He sug-
gested that the sequence found in the different
forms of malaria were the result of the periodical
discharge of foreign protein into the blood.
As a result of the brilliant results from the use
of diphtheria antitoxin, an effort was made to
provide a specific serological antagonist for each
*Presented before the Seventy-First Annual Session, Iowa State
Medical Society, Des Moines, Iowa, May 10, 11, 12, 1922.
of the clinical enemies of mankind. With the
possible exception of the antitoxins of diphtheria
and tetanus, most of these resulted in failure,
but it was noted that for some reason, certain
conditions improved on the injection of a serum
not prepared es])ecially for the condition in ques-
tion. For example, it was found that severe
cases of sympathetic ophthalmia were benefited
by heroic doses of diphtheria antitoxin, and that
inflammatory conditions obviously non-tubercular
were apparently relieved by injections of tuber-
culin. According to Miller (Biological Therapy,
p. 69) foreign protein therapy has been used in
practically all the infections with reported bene-
ficial results in many cases. The various forms
of arthritis and typhoid have received the greatest
degree of attention. He quotes reports from va-
rious observers as to their results in typhoid,
typhus, sepsis, pneumonia and various ocular le-
sions to be mentioned later. Some of the reports
were exceedingly striking, and while many of the
favorable results may be attributed to the over
enthusiasm of the observers, nevertheless, in spite
of a number of the reports being rather frag-
mentary and lacking in controls, he is of the
opinion that in some cases at least, the curative
value of this method of treatment was definitely
established.
Most authors advise the intra-muscular or at
least the sub-cutaneous route of administration of
foreign proteins, but in an unsigned editorial in
Medical Record, N. Y., Februar}', 1919, p. 200,
the author of the editorial not only gives the
serum for various ocular inflammations in this
way, but also advocates its administration by
mouth. He gives 10 c.c. (2500 units) in twenty-
four hours as a potion. He has observed very
prompt relief of pain and irritation and adds that
it greatly aids atropine in breaking down stubborn
synechia. He also found it to be of rather special
value in infections following operative proced-
ures.
Ben Witt Key (Arch. Ophth., November, 1919,
p. 581) in concluding a very comprehensive pa-
per on anti-diphtheritic serum in ocular infec-
tions, is convinced that favorable results with
388
Journal of Iowa State Medical Society
[October, 1922
para-specific therapy are by far in the majority.
He prefers the serum over other preparations, as
being more exact in dosage and its clinical action
better understood.
There has been considerable discussion as to
just how this form of treatment produces results.
Of course, in the specific antitoxins, as for ex-
ample, diphtheria, the action is probably direct,
while the benefit resulting from injections of the
same substance in a severe case of pneumonia or
other sepsis is not so clear. Peterson (quoted
above), mentions the theories of Vichardt, Star-
kenstein, Uithlen and others. Vichardt, in par-
ticular, regards the therapeutic effect in the na-
ture of plasma activation. This idea emphasizes
the fact that with the injections, the organism is
stimulated and that the “resulting reaction may
be a summation of all the forces of resistance
with which it is equipped.” Leucocytes are in-
creased in number and activity, enzymes are mo-
bilized and the glands of internal secretion stim-
ulated. He further points out, as has been em-
phasized by other observers, that when once the
organism is fatigued beyond the point of reaction,
repeated injections are of little value. Fradkin
(Clin. Ophthal., August, 1921, Abst. Brit. Jour.
Ophth., March, 1922, p. 135), speaking of injec-
tions of milk, “thinks its action is explained solely
by the fact that one introduces into the serum of
the organism a rich quantity of alexines which
destroy the microbes, already sensitized by their
specific fixation agent. Hence the remarkable
indifference to the kind of microbe which is ex-
hibited. It is not, in fact, a question of specific
medicament for a given race of microbes, but
of an aspecific substance, alexine, which is won-
derfully active on any kind of bacterial ele-
ment. Possibly the special advantage of milk
lies precisely in its great richness in alexines.
Speaking generally, I think we can safely say that
the value of non-specific administration lies in its
ability to raise the body resistance to its greatest
efficiency and it is only when this follows that
favorable results are obtained.”
We must of course bear in mind in using agents
of this kind, that they are not entirely harmless,
and that serious reactions may be produced. This,
however, may be said of almost any therapeutic
agent at our command and we must proceed with
caution until the tolerance of the patient is de-
termined.
As stated before, although parenteral specific
therapy has been applied to almost all phases of
inflammatory conditions, it has been given rather
special attention by the oculist, possibly because
in some forms of ocular inflammation we are
willing to try almost anything that will offer a
promise of help. In addition, we are able to ob-
serve the progress of improvement or lack of it
more or less accurately from day to day.
During the last four or five years, numerous
articles have appeared in ophthalmological jour-
nals dealing particularly with injections of steril-
ized milk. Some of these reports have been ex-
ceedingly optimistic while others have been quite
the reverse. Priority in the use of this particular
agent seems to be pretty generally given to Muller
& Thanner who published their first reports in
1916, but Jocqs (Clin. Ophthal., .May, 1921), re-
minds us that it had been used in general medi-
cine by the French investigators as early as 1903,
but evidently it was not generally adopted.
If we could expect to equal the results reported
by some of the more enthusiastic followers of this
method of treatment, our troubles in the care of
inflammatory diseases of the eye would be over.
For example, Bufil of Barcelona (Arch, di Oftal.
Hispano. Am. Barcelona, Aug., 1921, S. M. S. S.,
November, 1921, p. 56) reports seven cures, five
of them severe corneal infections, one of orbital
cellulitis and one of dacryocystitis. One of the
corneal cases was complicated with trachoma and
distichiasis. He is sure that injections of milk
are superior to all other agents in treating ocular
inflammations. On the other hand, Haller (Zeit.
f. Augenheil, xliv, p. 145) (Abst. Arch, of Ophth.,
iMarch, 1922) warns against the use of milk as
an inexact and dangerous procedure. Between
these extremes we find reports from men whose
experiences cover hundreds of cases and who are
apparently fair in their judgment.
Felix Jendralski (Zeit. f. Aug. No. 1, Berlin,
1921) used a milk preparation put out by the
Saxon Serum Works of Dresden under the trade
name of “Ophthalmosan.” His report covers 129
cases, a few of which were treated with boiled
milk. Fifty-nine of his cases were eczematous
conjunctivitis, of which twenty-six were cured,
with no result in thirty-three. He states that
other forms of treatment were used in connection
with the injections. Three cases of gonorrheal
conjunctivitis were improved and four not af-
fected. Four cases of serpent ulcer were not af-
fected, but four cases of corneal ulcer of other
types were arrested and cured. Two cases of
dendritic keratitis and nine cases of toxic iritis re-
sponded promptly to the treatment, while tuber-
cular and luetic inflammations were not affected.
These reports seem to be below the average and
it seems to be the general opinion that while the
dosage of ophthalmosan, duteroalbuminosis, etc.,
may be more exact and possibly less liable to pro-
VoL. XII, No. 10]
Journal of Iowa State Medical Society
389
duce anaphylactic disturbance, the results are not
so prompt nor effective as when the boiled milk
is used.
Cassumatia (Clin. Ophth., July, 1921) in re-
porting 134 cases treated by milk injections, men-
tions seven out of ten cases of hypopion keratitis
decidedly improved, the others not helped. Pain
and swelling rapidly subsided in fifteen cases of
purulent ophthalmia and healing of corneal com-
plications was materially assisted. Twenty-five
cases of trachoma were not affected, but six cases
of non-specific iritis were cured. He warns his
readers that the injection of milk is not a panacea,
but he is sure it has a definite field of helpfulness.
It would be burdensome to present even a con-
densed report of the numerous writers on this
subject, but I will give a brief summary of the ex-
periences of some twenty of our leading investi-
gators with special reference to the more common
ocular conditions treated. To my surprise, the
treatment of gonorrheal conjunctivitis heads the
list. Four report very favorable results, one neg-
ative and one three cures and four failures in
seven cases treated. Iritis and iridocyclitis were
favorably reported in every case, although one
failure was reported in a case of chronic choro-
iditis. Of the corneal infections of various
forms, of nine reporting, all noted improvement
except one. The simple ulcers seemed to respond
more favorably than the very violent serpigin-
ious type ; one case of dendritic keratitis re-
sponded rather promptly. One case of hyalitis
deserves special mention as the vision was im-
proved from less than 20/200 to nearly normal bv
nirie injections of milk at intervals of three days,
leaving the media practically as clear as the other.
Opinions vary as to the value of this treatment in
phlyotenular keratoconjunctivitis, about half the
cases showing marked improvement and the others
not helped. Luetic, tubercular and trachomatous
conditions were practically unaffected, although
pain when present was usually promptly relieved.
Four of them reported especially on the prompt re-
lief of pain and irritation and one emphasized
the promptness with which swelling and chemosis
were relieved. Six called attention to the value
of this procedure as a pre-operative and post-
traumatic prophylactic and single cases were
given of marked improvement in orbital cellulitis,
dacryocystitis, and intraocular hemorrhages. Two
spoke of the rather prompt relief of synechia
which had previously resisted the thorough use
of atropine. Practically all administered the
treatment intra-muscularly, although two injected
it beneath the conjunctiva, one in combination
with dionin instillations. Apparently the sub-
conjunctival injections were not as effective as
those given intra-muscularly.
Darier (Clin. Ophth., November, 1921) who
has perhaps had as much experience along the
line of para-specific theraj)y as any of our
oculists, thinks that in spite of some negative re-
sults, milk injections have given great satisfac-
tion in all fields of therapy and thinks it of es-
pecial value in the treatment of ocular inflamma-
tions. He is opposed to intravenous administra-
tion, considering it unnecessarily dangerous.
While in attendance at the International Con-
gress of Ophthalmology, in Washington, I took
occasion to speak to a number of the visiting
oculists as to their experience with this line of
treatment. Mr. Collins of London had not had
any personal experience with its use nor had Dr.
Magitote of Paris, although he had been carrying
on some experiments with other substances but as
yet has not come to any conclusion. Dr. Galle-
maert of Brussels has used it with considerable
satisfaction, especially in acute inflammatory
cases, but he thinks it is of certain value in other
conditions as well. Dr. Nordensen of Stockholm
has seen favorable results from its use and was
carrying on some experiments with special refer-
ence to vernal catarrh, but as yet had not come to
any positive conclusions. Dr. Parker of Detroit
has seen some very favorable results from the
use of para-specific therapy but uses tuberculin
and diphtheria antitoxin in preference to milk,
owing to the ease with which it can be procured
and administered, but is of the opinion that the
milk would probably be equally beneficial.
Our personal experience with para-specific
therapy extends over the last five or six years,
at first limited to injections of diphtheria anti-
toxin and tuberculin in very severe cases of
uveitis, and occasionally used anti-pneumococcus
serum in cases of serpent ulcer. The results in
these cases were very indefinite and as they were
used only in most unpromising conditions and
often as a last resort, I could not say that we
could definitely report any favorable results from
their use.
Within the last six months, we have used intra-
muscular injections of sterilized milk in nineteen
cases, in some of which we could see no apparent
benefit, while in others it .seemed as though some
improvement could be traced- to the injections.
Of these cases, two had choroiditis, two inflam-
matory glaucoma, four iritis and cyclitis, one
traumatic cataract, three neuritis, six corneal ul-
cer, one panophthalmitis and one penetrating
wound. We used whole milk boiled for four
minutes and the injections were from one to ten
390
Journal of Iowa State Medical Society
[October, 1922
cubic centimeters and were usually repeated in
from twenty-four to forty-eight hours. It has
been our experience in common with other ob-
servers, that unless the patient shows improve-
ment on the first two or three injections, there is
no benefit to be gained in pushing them further.
Furthermore, in no case did we limit our therapy
to the milk injections alone, so it would be impos-
sible to determine whether the improvement was
due to the milk or to other lines of therapeutic
attack. However, in a number of cases, the im-
provement was so prompt following the milk
iniections that we felt that there must be a defin-
ite connection. One very discouraging case of
old choroiditis with partial retinal separation
really made some improvement on repeated in-
jections of two c.c. of milk. Of course this may
have been due to other lines of therapy which
were employed but the improvement seemed to be
coincident with the use of milk. One case of
iridocyclitis with severe pain and a rapidly ad-
vancing plastic exudate which looked like begin-
ning panophthalmitis was relieved in a few hours
of pain and irritation by one injection. The in-
jection was repeated in forty-eight hours. Im-
provement was uninterrupted, the pupillary space
being practically clear in three days. This again
may have been a coincidence as he told us he had
had similar attacks which had been equally severe
but which had cleared up on ordinary treatment,
but as he had been rapidly getting worse up to
the injection of the milk, I am convinced that it
had a very beneficial influence. One case of ser-
pent ulcer was a complete failure. In spite of
the use of every therapeutic measure at our com-
mand, including optochin, thermophore, sub-con-
junctival injections of cyanide of mercury, de-
limiting keratotomy, and repeated injections of
milk, the cornea melted out in about forty-eight
hours, but this was in an elderly man of very low
resistance very susceptible to pain and it is a
question in a case of this kind, as has been pointed
out by others, whether the use of foreign protein
may not be harmful rather than otherwise. It has
been our experience that serpent ulcers which do
badly are almost invariably in patients of this
type, which leads one to suspect that the unfavor-
able outcome is in all j)robability due more to low-
ered resistance than to any unusually virulent type
of infection. Five cases of superficial corneal
ulcer, one in a child of one and a half years, im-
proved on regular lines of treatment plus injec-
tions of milk. In one case we felt the improve-
ment could be definitely attributed to the milk.
In the others, it was of course doubtful. Pain
was decidedly relieved in three cases of inflam-
matory glaucoma, two of them post-traumatic,
while three cases of optic neuritis improved on
milk plus other measures. We have only used it
once as a prophylactic following a severe pene-
trating wound with uveal prolapse. The case pro-
gressed very favorably, which might have been
the case either with or without the injection. Two
cases of iritis and one of severe cyclitis following
a penetrating wound were improved so far as pain
was concerned, and as they were severe cases and
eventually turned out favorably, I am inclined to
think the milk had a real curative value.
Of our cases, three may be said to be complete
failures so far as injections of milk are con-
cerned, but as one of them was a case of rapidly
progressive panophthalmitis, nothing could be ex-
pected. The second was a slowly progressive
hyalitis which, contrar}’ to the experience of one
of the observers mentioned above, went from bad
to worse in spite of all we could do, and the third,
the case of serpent ulcer mentioned above. Seven
cases of improvement could apparently be traced
rather definitely to the injections of milk, while
the improvement in the remaining six may have
been due equally or entirely to the other lines of
therapy. Our injections varied from one to ten
c.c. in amount, averaging about 5 c.c., the largest
number given in any case being five. Our expe-
rience coresponds to that of others who have
found that unless improx ement is noted after two
injections, it is useless to continue. It was at
first thought that unless there was a decided fe-
brile reaction, there would be no therapeutic re-
sult. Recently there seems to be a decided change
of opinion as to this and it is certainly not true
in our experience, the cases which showed a de-
cided rise in temperature doing no better than
those that did not.
In conclusion, I think we may fairly assume
both from the standpoint of the general practi-
tioner and the specialist that the employment of
para-specific therapy is a real addition to our
armament. Neither in our experience nor in the
reports that I have read have I seen any harmful
results from the milk injections, but like any
other therapeutic procedure, it must be used with
judgment after a careful study of the individual
reaction of the patient. We must not be over in-
fluenced by the too enthusiastic reports of certain
observers nor unduly cast down when our results
fail to come up to their standards. Neither do I
feel that we are justified in disregarding old and
tested methods in a given case, but where para-
specific therapy can be employed in connection
with our regular procedure, it is certainly our
duty to give the patient the advantage of its use
VoL. XII, No. 10]
Journal of Iowa State Medical Society
391
and even though the effects may be transitory or
even limited to the reduction of discomfort, it is
well worth the effort.
THE OCCULT DISEASE OF CHILDHOOD*
J. Claxton Gittings, M.D.
Professor of Pediatrics in the Graduate School of
Medicine, University of Pennsylvania
M e will begin to-day’s lecture with case his-
tories which will illustrate the features of the dis-
ease without any intimation at first as to the diag-
nosis.
The patients whose histories are to be given
were seen recently in the Medical Service of the
Children’s Hospital, Philadelphia, and all of them
were suffering from the same disease. This will
demonstrate very well the^rotean characteristics
of the symptomatology and the reason why the
correct diagnosis often is missed at first.
Case I. Male, five months old. On the day be-
fore admission he had had a slight convulsion and
was feverish and restless. On the day of admission
another convulsion occurred after which, the mother
stated, the "right arm and leg appeared to be weak.
He vomited once and the bowels moved several
times. Examination on admission showed slight
stupor with rigidity of the neck but no definite evi-
dence of hemiplegia. The spinal fluid was under
slightly increased pressure but otherwise was nor-
mal, with four cells per cm. The leucocytic count
was 19,600. The temperature ranged from 100° to
103^^° F. on the first day and continued an irregular
course, tending to a lower range, for two weeks. He
left the hospital greatly improved, four weeks after
admission.
Case II. Girl, three and one-half years old. Two
days before admission she became feverish, drowsy
and complained of pain in the stomach. There was
no vomiting and the bowels were constipated. On
admission, physical examination was negative. She
ran an irregular temperature for the first five days,
varying from 100° to 106^° F. After ten days of
normal temperature, there was a recrudescence for
three days, reaching 102° F. The leucocytic count
was 28,400. There were no noteworthy symptoms
while she was in the hospital and she left on the 27th
day, perfectly well.
Case III. Girl, eight years old. For several
months she has been subject to attacks of abdominal
pain, diarrhoea, vomiting and disturbed sleep. Apart
from bad teeth, examination on admission was nega-
tive. The leucocytic count was 11,000. The tem-
perature never exceeded 100^4° F. After an unevent-
*Delivered before the Tri-State District Medical Association, Mil-
waukee, Wisconsin, November 15, 1921. From the Medical
Service of the Children’s Hospital, Philadelphia.
ful course of two weeks she left the hospital greatly
improved.
Case IV. Girl, six years old, who gave a history
of frequent “colds” and eneuresis. Two days before
admission she suddenly developed fever, complained
of general aching and was unable to stand on ac-
count of pain in the hips and feet. There was com-
plete anorexia, with occasional vomiting, and con-
stipation. The temperature was 103° F. on admis-
sion but fell to normal on the third day. The leuco-
cytic count was 19,200. Physical examination was
negative so far as a cause for fever was concerned.
With the cessation of fever, all subjective symptoms
disappeared and she was taken from the hospital in
eight days greatly improved.
Case V. Boy, five and one-half years old. One
week before admission he became feverish, com-
plained of chilliness and pain in the right knee and
ankle and, later, in the abdomen. Anorexia, occa-
sional vomiting and thirst were the only other symp-
toms. Examination was negative as to a cause for
the pain and fever, which ran an irregular course for
eight days ranging between 98° to 99° and 101° to
103° F. After twenty-six days he left the hospital,
practically well.
Case VI. Girl, ten months old. Two weeks be-
fore admission she began to vomit after meals, and
later had diarrhoea. On admission the temperature
was 99° F. and ranged between 97° and 99%° with
occasional rises to 100%° or less. Physical examin-
ation was negative except for marked dehydration.
Apathy, extreme anorexia, occasional vomiting and
slight intestinal indigestion have been the only note-
worthy symptoms. The blood-count showed 3,250,-
000 erythrocytes, 29,300 leucocytes and 57 per cent,
hemoglobin (Sahli). In addition to iron citrate by
hypodermic injection she has received one transfu-
sion of blood. She is still in the hospital after seven
weeks but probably will recover.
Case VII. Girl, seven years old. On the day of
admission she became feverish and complained of
left-sided abdominal pain and nausea. During the
night she vomited several times and passed urine fre-
quently. On admission the temperature was 104%°
F. and ranged between that and 100° F. for six days.
The abdomen was tender, with slight rigidity on the
left side. On the next day these signs had disap-
peared and she left the hospital in eighteen days
greatly improved.
Case VIII. Girl, three years old. Four weeks
before admission she had suddenly developed fever,
vomited several times, sweat profusely and had a
convulsion. Anorexia was complete and she com-
plained of thirst, pain in the right lumbar region and
severe dysuria. The convulsion was not repeated but
the other sj^mptoms persisted, in a modified form,
until admission. Examination showed slight tender-
ness in the abdomen and in both lumbar regions,
which gradually disappeared in four or five days.
The temperature was normal except for several sud-
den rises to 101° to 104° lasting for two or three
392
Journal of Iowa State Medical Society
[October, 1922
days. The leucocytic count was 10,200. After five
weeks she left the hospital, improved but not cured.
Comment
It will be noted that fever was the only symp-
tom which was common to all of the.se cases and
that even the fever was a variable factor. \'om-
iting occurred in seven of the eight cases. In
other respects the symptoms varied from those of
a meningitis to those of a simple attack of “func-
tional” diarrhoea. In every case physical examin-
ation failed to reveal the cause of the attack and
in every instance the diagnosis depended solely
upon the examination of the urine. This showed
consistently an acid reaction, more or less al-
bumin and a moderate or excessive number of
leucocytes. Upon these findings, in the absence
of other cause, was based the diagnosis of pyel-
itis. In only two of the eight cases had there been
any symptomatic evidence of disturbance in the
urinary tract.
During the past two decades pyelitis has come
to be recognized as one of the usual diseases of
childhood. Richard Smith estimates its incidence
at about 1 per cent, of all children coming under
treatment. In a recent survey of 734 febrile cases
treated in the medical wards of the Children’s
Hospital, Philadelphia, 12 or 1.6 per cent, had
pyelitis.
You will find no mention in the older paediatric
literature of the type of pyelitis illustrated by
these cases. Even in the four volumn “Encyclo-
pedia of the Diseases of Children” published in
1890, the only condition considered is that of
pyonephrosis which is described as hydronephro-
sis with pyelitis superadded, due primarily to me-
chanical obstruction to the outflow of urine. The
most important cause, apart from congenital de-
fects, seems to have been renal or cystic calculi.
It appears therefor that only severe forms of
pvelitis were recognized. Erom what is known
of the etiology of pyelitis, there is no reason to
believe that it was any less common then than at
present. On the contrary it probably was more
common, owing to the greater incidence in those
days of diarrhoeal diseases. It seems probable
that primary forms masqueraded under the guise
of “difficulties in teething” or “gastric fever” —
to use some of the favorite diagnoses of the past.
These primary forms of pyelitis, as diagnosed to-
day, certainly do not require any mechanical urin-
ary obstruction for their causation.
In the same volumn we find the statement by
William Hunt that from 50 to 60 per cent, of
cases of stone in the bladder occurred in children
under sixteen years of age, while renal calculi, ac-
cording to Henry Morris, were found “very com-
monly” in the children of the poor up to the age
of fifteen. The latter fact was ascribed, among
other things, to absence of milk in the diet and to
the use of indigestible articles of food. That both
renal and vesicle calculi in children are much less
common of late years will be attested by surgeons,
while “pyonephrosis” is a rare disease. This sug-
gests the possibility that the frequency of lithiasis
in the past was dependent in part upon the fre-
quency of pyelitis, which, unrecognized and not
treated, furnished the infective nidus without
which calculi do not form.
Etiology
We may consider pyelitis as occurring in two
forms : ( 1 ) The so-called primary form in which
we are chiefly interested and (2) the secondary
form which occurs as a complication of other dis-
eases. In both forms the exciting cause is bac-
terial, the B. coli, streptococcus, staphylococcus,
pneumococcus, B. lactis aerogenes, etc.
There are three chief theories as to the manner
in which the bacteria reach the kidney — (1)
ascending infection through the ureter, (2) lym-
phogenous transmission directly from the bowel
and (3) hematogenous infection. To these may
be added transmission through the lymphatics of
the pelvis or the periureteral lymphatics.
The chief argument in favor of ascending in-
fection through the ureter is the preponderance
of cases among girls, almost three to one, and the
ease with which the urethral orifice in girls is
contaminated with intestinal bacteria.
As Richard wSmith points out, however, this
contamination involves other structures than the
urethra. He found positive cultures from the
vagina in each of forty babies and young children,
beginning from the sixth hour to the sixth day of
life — the majority occurring as early as the
eighteenth hour. The lymphatics which drain the
vaginal and pelvic organs have a free anastomo-
sis with those of the kidney, and both, of course,
empty into the blood stream through the thoracic
duct.
Under experimental conditions Helmholz and
others have been able to infect the pelvis of the
kidney by injecting B. coli into the bladder. It
was clear, however that the infection often
reached the kidney by way of the periureteral
lymphatics and absolute proof was lacking of the
entrance of the bacteria into the pelvis solely
through the lumen of the ureter. That infection
by either route occurs under normal conditions
when comparatively few bacteria gain access to
the bladder in human beings seems most unlikely.
VoL. XII, No. 101
Journal of Iowa State Medical Society
393
This is increased by the fact that in his experi-
mental animals Helmholz always found acute in-
flammator}' reaction in the wall of the bladder
after the intracystic injections. If pyelitis in chil-
dren is caused by organisms that gain entrance
through the urethra they would be expected to
set up first a cystitis, whereas cystitis usually is
only a late complication of severe cases.
Helmliolz’s studies on the bacterial content of
the urethra in girls showed that the B. coli is not
a normal inhabitant over two years of age. Un-
der that age he found the bacillus quite frequently,
especially during the course of extra-urinary in-
fections. He ascribed this to the greater diffi-
culty in cleansing and disinfecting the urethral
orifice in girl babies. It is also very difficult to
insert the catheter cleanly into the orifice without
touching the outer edge. By drawing the urine
separately into a first and second portion, 'Helm-
holz was able to determine that the infection was
present in the orifice and the urethra and not in
the bladder.
Since Frank drew attention to the lymphatic
connection which exists between the colon and the
right kidney it seems quite possible for a pyelitis
or renal infection to result from direct transmis-
sion from the bowel. Its relative importance can-
not be stated but at least it fails to explain the dis-
crepancy in sex incidence.
Hematogenous infection can occur in any or-
gan of structure- which is well supplied with
blood. Pathogenic organisms may pass through
an organ without setting up any recognizable dis-
ease, as occurs when typhoid bacilli pass through
the kidneys. On the other hand, various organ-
isms which are brought to the kidney by the blood
stream may set up focal disease in the parenchyma
or cortex or may pass through and cause infection
below the secreting structures — primarily in the
pelvis. For example, Helmholz injected the ear
vein in a series of sixty-six rabbits with different
strains of B. coli. In twenty-six of the rabbits,
various focal lesions were produced, often multi-
ple. In eleven cases the kidney was involved,
chiefly in the form of focal abscesses, while in
only two was the pelvis alone effected. Other
lesions were produced twenty-six times in various
organs, chiefly the gall-bladder and caecum, as
compared with eleven renal infections. When
pneumococci were combined with B. coli, and
seven rabbits injected, three showed pyelitis alone,
one a cortical renal abscess and two had renal
hemorrhage, while lesions of other organs oc-
curred only four times. These results open up
the complicated question of symbiosis but are in-
teresting as proving that renal lesions can be pro-
duced by a purely hematogenous route. The fact
that so many multiple lesions and extra-renal le-
sions resulted tends to throw some doubt upon
hematogenous infection as the principal cause of
human pyelitis although Rosenow has shown that
certain bacteria apparently possess definite selec-
tive action in their localization. For example
streptococci cultured from renal lesions tend to
produce a higher percentage of renal infections in
experimental animals than do those from other
sources. In this light, the special type of the in-
fecting organism may be the chief determining
factor in the pathogenesis.
In all of Helmholz’s cases of experimental
pyelitis, the chief inflammatory reaction occurred
in the papillae, whereas the pyelitis which followed
intracystic injection involved chiefly the parietal
portions. Helmholz believes that, so far, this con-
stitutes the only histological distinction between
hematogenous and ascending infections.
The whole subject of the mode of infection is
still sub judice. W hatever the final decision may
be, in part it probably will involve the sexual an-
atomy since the preponderance of pyelitis among
girls is too great to be explained on any other
basis.
Pathology
In a recent paper before the American Pedi-
atric Society Helmholz emphasized the impossi-
bility of determining, intra-vitam, the exact site
of infection of the urinary tract. In simple un-
complicated cases of pyelitis such as we are illus-
trating, it has been believed that the lesions at
first involved only the structures of the pelvis but
in the pathological study of certain specimens
from fatal cases of clinical pyelitis Helmholz was
unable to find any histological change in the pelvis
Itself. This apparently lines up the whole ques-
tion of pathologA’ with that of the mode of infec-
tion, and throws stress upon the importance of
bacteriologic studies in fatal cases
The findings of so-called “pyelitis,” such as pus
cells and positive cultures, therefore indicate
merely the presence of a urinary infection. Onlv
with cystoscopic examination, urethral catheteri-
zation and x-ray studies can we hope for greater
accuracy in determining the exact size of the dis-
ease. Fortunately, however, the average case can
be diagnosed with reasonable accuracy by com-
paratively simple methods and we are justified in
retaining the clinical designation “pyelitis,” if we
always bear in mind the possibility of the exist-
ence of the other lesions.
Symptomatology
The cases which have been detailed illustrate
practically all of the important symptoms of sim-
394
Journal of Iowa State Medical Society
[October, 1922
pie pyelitis. Without examination of the urine
accurate diagnosis is impossible. It should be
emphasized, however, that whereas pyelitis may
be primar)' without any antecedent disease, in-
testinal disorders very frequently preceded the
attack. Adherents of the theory of direct infec-
tion from the bowel emphasize this but, as stated,
it fails to explain the sex incidence. It seems
rather to point to infection from vaginal or
urethral contamination. Xot rarely an apparent
primary' attack is but a recrudescence of a chronic
infection. There is also reason to believe that
reinfection occurs. Xone of the usual organisms
involved confer any lasting immunity and the
original avenues of infection certainly may be
open.
The secondary form of pyelitis occurs occa-
sionally in the course of one of the other infec-
tious diseases such as typhoid fever or pneumonia.
In any recrudescence or increase of fever in such
diseases the urine should be reexamined.
According to the modern theory of hematogen-
ous infections, we may conceive that diseased ton-
sils, teeth, sinuses or other localized abscesses can
furnish the infective material and quite recently
Bumpus and Meisser succeeded in producing
renal lesions in 76 per cent, of eighty-two rabbits
which had been injected with streptococci re-
covered from teeth, tonsils, urine and blood of
seven adult patients suffering from pyelitis. Again
this seems to point to a selective localization on
the part of these streptococci. Since the infec-
tive focus in five of the seven patients was in the
alveolar processes, the applicability of the results
to children is open to question, and the increasing
number of instances where the tonsils have been
enucleated will enable us soon to judge of the
importance of the tonsils. Compared with intes-
tinal disturbance and its consequent local con-
tamination, hematogenous infection from such
sources, however, must play an unimportant role,
and again, it fails to explain the preponderance of
cases among girls.
Diagnosis
The diagnosis of pyelitis in a child can be made
tentatively in less time than is required to de-
scribe it. A drop of urine on a slide without a
cover glass is examined with the high power “D”
objective. If the number of leucocytes exceeds
ten per field there is great probability of pyelitis
being present. Other specimens must be exam-
ined before a final diagnosis is made. In true
pyelitis the number of leucocytes will increase.
Certain precautions must be taken — (1) the
urine must have been passed within two or three
hours unless it has been kept at a low tempera-
ture— 45° or less. In any- event, not more than
ten to twelve hours should have elapsed. (2)
The urinary meatus in both sexes, and the vaginal
orifice in girls, must be free from any signs of
inflammation or discharge. (3) The urine must
be thoroughly mixed before putting the drop on
the slide. For this reason it is better to use un-
centrifugated or unsedimented urine.
Under conditions one or two the urine will al-
most invariably be acid, if no alkali has been given
to the child, and usuall)' contains at least a trace
of albumin. Small epithelial cells may or may
not be abundant. Occasionally we find a few
casts but their constant presence or a large num-
ber indicates that we may be dealing with an in-
fection of the kidney itself. An alkaline urine,
freshly passed, containing triple phosphates and
large epithelial cells suggests a pyelocystitis, since
cystitis alone is rare, apart from local causes such
as traumatism, vesical growth, etc.
If there is any doubt as to the presence of local
irritation u hich might vitiate the leucocytic count
and if, at the same time, the diagnosis is not clear,
the child should be catheterized with the precau-
tions to be detailed later, and a bacteriological
study should be made. If, on the other hand, the
number of leucocytes is below ten per field, the
count should be repeated daily for several days,
as a single specimen may, for various reasons,
give inconclusive results.
If the count continues to be suspicious, from
five to ten cells, and the diagnosis still be in doubt,
the child should be catheterized for a bacteriolog-
ical study of the urine.
In a true case of pyelitis the early’ samples of
urine may show comparatively few cells in a rel-
atively clear urine, but in a short time the cells
show a marked increase and the urine will become
more or less cloudy. Sooner or later, cultures will
prove to be positive but in general practice a
culture usually is not necessary' for diagnosis and
successful treatment. In doubtful cases cultures
are essential.
At the Children’s Hospital we secure a sample
of urine from little girls as follows :* Through a
piece of adhesive plaster approximately three
inches square two median slits are made at right
angles just large enough to admit the flange of an
ordinary two or three ounce glass bottle, passing
the latter through from the “back” of the plaster
to the “adhesive” side. Each corner of the plaster
is slit up one and one-half to two inches to pro-
vide for a tight apposition. The plaster can be
made to fit the bottle tightly by wrapping an ex-
*This method is not original but we regret that we are unable
to recall the name of the originator.
VoL. XII, No. 10]
Journal of Iowa State Medical Society
395
tra piece around the neck and is then applied over
the vulva so that the mouth of the bottle lies just
at the urinary meatus. By carefully fitting the
lower end of the plaster in front of the anus it is
possible to avoid fecal contamination even in the
presence of diarrhoea. The bottle can be held
loosely in place by the diaper. The only contrain-
dication to the method is dermatitis or severe ir-
ritation of the vulvcC and perineum.
Catheterization
Two objections are inherent to catheterization
in these cases, one of introducing new or mixed
infection and the other of obtaining positive cul-
tures from accidental contamination and thus
causing error in diagnosis. It is often stated that
the introduction of a few bacteria on the catheter
is never followed by infection. Although there
is much evidence in favor of this contention, in
view of the undoubted presence of various patho-
genic bacteria from the intestine and the lowered
resistance of the child, it certainly seems more
rational to take every precaution against infection.
Many types of technique have been employed
but none is altogether satisfactory. The import-
ant points are to keep the labia separated and to
attempt to cleanse only the vestibule and urethral
orifice without touching anything else. For
cleansing, tincture of green soap and distilled
water followed by bichloride of mercury solution
( 1 to 1000) and distilled water, may be used, or a
2 per cent, solution of lysol may be followed by
distilled water. The solutions and water may be
applied by douching freely, using a medicine drop-
per or small syringe. Great care must be taken
to insert the catheter cleanly without contact with
any other part or object. The urine should be
collected in two portions and only the last used
for culture. Before withdrawing the catheter the
bladder should be washed out with 5 per cent
boracic solution.
The acute case of pyelitis under appropriate
treatment usually makes a prompt symptomatic
recover}' but eradication of the infection often is
extremely difficult. When fever and constitu-
tional symptoms persist beyond three or four
weeks, in spite of treatment, there is probability
that the renal structure is involved. Fatalities are
due usually to severe anaemia and parenchymatous
degeneration of various organs due to prolonged
sepsis, to pyaemia with secondary abscesses, pneu-
monia, etc., or to “surgical kidney.” Very rarely
does the disease prove to be tuberculous or malig-
nant.
There is a large percentage of cases that, in
spite of treatment, continues to show pus cells in
the urine. In some of these the anaemia, anorexia,
lack of energy and slight or occa.sional fever sug-
gest a variety of causes and such cases are often
incorrectly diagnosed. In others there may be
little apparent effect upon the child’s health. How
many of both of these types finally recover and
how many drift into more severe and fatal forms
of urinary disease or die of anaemia, sepsis and ex-
haustion, is problematical. Some authorities be-
lieve that some of the cases of pyelitis or pylone-
phritis of adult life had their inception in these
attacks of childhood.
Treatment
Apart from the removal of possible foci of in-
fection the greatest importance in the treatment
of pyelitis attaches to securing free drainage by
supplying large amounts of water. When this is
refused or vomited, it may be given by the nasal
rather than by the stomach tube, as the former is
less apt to cause gagging. From 500 to 750 c.c.
(16 to 24 ounces) of water should be given to in-
fants daily in addition to other liquids, with large
amounts to older children. By determining the
specific gravity of the urine we can make an es-
timate of the degree of urinary “dilution.”
When vomiting is persistent, water should be
given by the intraperitoneal method. Case VI in
this series has received forty intraperitoneal in-
jections, without which, it is fair to say, recovery
would have been impossible.
The next measure in importance is to secure
complete alkalinization of the urine. Citrate of
soda is better borne by the stomach than bicarbon-
ate of soda and both can be given safely in larger
doses than can the salts of potash. All of these
may be used but enough must be given to keep the
urine constantly alkaline. In infancy, four grams
(sixty grains) of sodium citrate a day may be the
“basic dose,” with one to two grams (fifteen to
thirty grains) of the bicarbonate or- potash salt if
needed. The largest single dose should be given at
night to carry over the period when acidity is
highest and intake lowest.
Usually there will be definite improvement in
the fever and toxic symptoms after four or five
days of the alkaline treatment. Ji-ist how it acts
is unknown. While improvement lasts, the alkali
can be continued, so long as there are no signs of
over alkalinization such as a positive reaction to
thymolphthalein (.5 in 100 c.c. alcohol). If no
improvement occurs in five days, we may try
hexamethylenamin. This must be given in large
dose, at least one gram (fifteen grains) in twenty-
four hours for infants of five or six months.
Since this drug will not be liberated in alkaline
396
Journal of Iowa State Medical Society
[October, 1922
urine, all alkali by mouth must be stopped. Acid
sodium phosphate or dilute hydrochloric acid may
be used to render the urine acid.
W ith a free supply of water there seems to be
little danger of hematuria but the treatment
should not be continued steadily for more than
six or seven days and may be followed by an-
other course of alkali. This alternation may be
continued at weekly intervals and often will be
completely successful. WTen the pyuria persists
we may try an autogenous vaccine, although too
much should not be expected from it. Recently,
the injections of silver salts into the pelvis by
urethral catheter have given excellent results.
For example, Kretschmer and Helmholz report
complete cures in nine of eleven cases ranging in
age from seven months to ten and one-half years,
using a .5 per cent, solution of nitrate of silver.
In all severe chronic cases the secondary
anfemia indicates the use of iron. Probably the
best results are obtained by hypodermic injections
of iron citrate. Arsenic should not be used. In
the worst types blood transfusions are indicated.
The selection of a suitable diet is of definite
value. During the stage of alkalinization, the free
use of green vegetables and orange juice aids in
reducing acidity of the urine and stimulates di-
uresis. The vegetables may be fed to babies in
the form of purees or as vegetable soup. ]\Iany
green vegetables have the additional advantage
of being natural hematinics. The only contrain-
dication to their use is intestinal indigestion or
vomiting. If there is dificulty in securing an
acid reaction for treatment with hexamethylena-
min, vegetables may be stopped and lactic-acid
milk, made palatable with sugar or saccharin, may
be used as the chief food.
In the mild types, when all treatment fails to
clear the urine, a trial should be made of the
“fresh air cure.” For all the severe types and for
the most stubborn mild types expert urological
advice should be sought. The importance of per-
sistence in treatment lies in the potentialities for
serious or fatal disease which exist when there is
definite infection of the urinarv- tract.
Prevention
In the absence of definite knowledge as to the
exact modes of infection, prevention must be
somewhat empirical. Cleanliness probably is of
greatest importance. During attacks of diarrhoea
particular care should be taken to cleanse the
vulvae as promptR as possible after soiling has oc-
curred. For this purpose the child should lie on
one side, instead of on the back, and all pressure
should be made from before backward. After the
gross cleansing, sponging may be done with one
per cent, lysol solution on a sterile cotton pledget.
The free use of water internally in such cases and
in the infectious diseases has other advantages
than those usually ascribed to it, since polyuria
probably means a lessened chance for urinary in-
fection.
PSYCHIATRIC ANALYSIS OF THE CHIL-
DREN IN THE STATE JUVENILE
HOME
Lawson G. Lowrey, M.D., Assistant Director
John J. B. Morgan, Ph.D., Psychologist
Iowa State Psychopathic Hospital
In the early part of the summer of 1921 Super-
intendent Kepford of the State Juvenile Home
brought to the Psychopathic Hospital for ob-
servation a girl who had shown in her behavior
rather marked departures from normal. At this
time he told us of the nature of his work and
that he had at the home a number of children
who showed rather striking deviations from the
normal. As a result of this conversation a psy-
chiatric survey of all the children in the home
was undertaken. The first trip to Toledo was
made in September. Dr. Morgan made a second
trip in November and the third trip was made
in the early part of February. While time limita-
tions made it impossible to study many of the
children as thoroughly as we should like, we felt
that on the whole a fairly adequate survey was
made of the total of 141 children, varying in age
from four to seventeen.
The method employed may be of some interest.
We were searching primarily for the feeble-
minded children. On the first visit practically all
children in the home ten years of age or over, a
total of sixty-eight, were given a group test, using
Dr. Morgan’s group test for which the norms
have been carefully worked out ; a relatively sim-
ple scheme whereby the individuals taking the
test work for forty minutes, going as far as they
can in the time given. Those who made scores
of twenty-one or less on the Morgan test and
those who made exceedingly high scores were
then given the Binet test. At various times. Dr.
Morgan gave individual tests to a total of 122
children. Dr. Lowrey examined the children
with low ratings and those reported by the super-
inteiKlent or by the teachers to be difficult prob-
lems in any way. He was searching more for
manifestations of emotional and volitional disor-
ders, for neurological signs of organic brain dis-
ease, for indications of congenital syphilis, and
VoL. XII, No. lOJ
Journal of Iowa State Medical Society
397
the various so-called stigmata of degeneration.
He also endeavored to check by brief mental ex-
amination the findings of the psychometric tests,
seeing a total of sixty-three of the 141 children.
Enuresis, fainting spells, nervousness, somnam-
bulism, running away, fits of temper, and visions
were inquired into ; in the older girls the men-
strual history was gotten, and in the older girls
and boys one or two careful questions were asked
to ascertain whether or not they had knowledge
of sex matters. If it was found that they did
have such knowledge, then one or two careful
questions were asked to determine whether or not
there had been illicit sexual experiences or mas-
turbation. While there was in general no way to
ascertain whether or not the children were truth-
ful about such matters without pursuing the in-
quiry to a point which seemed unwise, in general
their stories agreed with the facts which the su-
perintendent was able to give us. With the
younger children no attempt was made to ap-
proach this topic unless they indicated by their
statements that there was positive knowledge or
experience to be looked into. Although it must
be admitted that such a sketchy analysis of the
sex problems of these children will fail to reveal
many facts having a bearing on their behavior, it
seemed to us desirable to err on the conservative
side in approaching these problems with this pop-
ulation of presumably normal children.
We then turned to the records which accom-
panied the children to ascertain such facts as the
age and date of birth and such material as there
might be concerning the family history. In gen-
eral the records as to the family history were
very scanty. We did not get, therefore, the in-
formation that seems desirable to complete an
investigation according to the ten field scheme
laid down by Fernald. In many cases the birth
records are uncertain, but sometimes they can be
fixed by the statements of the children. Never-
theless we are left with eight cases in which the
age is sufficiently in doubt to lead us to list them
as uncertain. It will be seen that we have the
following positive information to deal with :
1. Psychometric examination of the child.
2. Report of the officers of the home con-
cerning the school work and the conduct of the
child.
3. In a considerable number of cases a brief
physical, neurological and mental examination.
4. In a few cases the family history.
With these data we have been able to pick out
the following groups :
1. The definitely feebleminded.
2. The border line retarded cases, which may
or may not turn out to be feebleminded — for re-
e.xamination at the end of a year.
3. Certain psychopathic personalities of con-
siderable interest.
4. Certain cases of glandular disorders,
chiefly hyperthyroidism.
5. Some suspected cases of congenital syphilis
(in this connection it seems highly desirable to
have Wassermann tests made on all children ad-
mitted).
6. Normal children.
The age distribution of these children is as
follows :
4- 5 1
5- 6 3
6- 7 6
7- 8 6
8- 9 15
9- 10 11
10- 11 14
11- 12 22
12- 13 9
13- 14 22
14- 15 14
15- 16 7
16- 17 2
17- 18 ]
Uncertain 8
141
There are thirty-thred family groups in the in-
stitution ; that is, where more than one child of a
family is present. There are twenty-one families
with two children, five with three, and seven
with four, so that 85 of the 141 children belong
to these thirty-three families. There were sixty-
four girls and seventy-seven boys. On the whole
we may regard this as a fairly average sample of
“neglected and dependent children” sent to the
.State Juvenile Home.
All the facts of observation which can be so
tabulated are given in Table I. The following
discussion, with the exception of Dr. Lowrey’s
observations, may be verified by reference to that
table.
Results of the Morgan Test
The sixty-eight children who took the group
test fall into the following age groups : Nine
years, 5; ten years, 5; eleven years, 15; twelve
years, 8; thirteen years, 16; fourteen years, 11;
fifteen years, 4; sixteen years, 3 ; seventeen years,
1. The highest score, 99 (of a possible total of
190 points) was made by a twelve year old girl.
Only one other score over 90 was made, a seven-
teen year old girl scoring 95. Two scored from
80 to 90 ; three from 70 to 80 ; five from 60 to 70 ;
398
Journal of Iowa State Medical Society
[October, 1922
ten from 50 to 60; twelve from 40 to 50; nine
from 22 to 39 inclusive ; twenty-five from 0 to 21.
The scores arranged by ages were as follows ;
Age
Score
Age
Score
9
1
13
0
2
1
6
8
10
10
47
29
40
42
48
10
3
51
16
52
27
53
28
55
35
57
67
72
82
11
0
—
1
14
1
1
3
1
11
9
13
10
21
20
40
24
49
24
55
29
60
Twin
32
73
Twin
40
82
40
48
15
54
56
69
69
71
12
39
16
45
44
54
47
57
64
99
17
95
In general, the feebleminded children made
very low scores on this test. The score of 47
made by a nine year old girl (having an I. O. of
1.03) was exceeded by only two feebleminded
children, one a girl of fifteen, scoring 69; the
other, a girl of sixteen, scoring 54. No other
feebleminded child scored over 24 on the test.
Some normal and psychopathic children scored
lower than 24, but in each case this was found to
be due to lack of education (the test requires
ability to read, write and do simple arithmetic,
being especially intended for adults and older
children). The test, therefore, allowed us very
quickly to select the children for individual ex-
amination.
General Findings
We can most profitably first discuss the fam-
ilies.
Family 1. A girl of twelve years nine months
scoring 47 on the Morgan test and a boy of eleven,
with Binet age of seven years nine months. The boy
is certainly feebleminded and the girl probably nor-
mal, though they were removed from the home be-
fore our study was completed. No family history
available.
Family 3. All of these three boys are feeble-
minded. Father described as lazy, improvident
roamer; very slow in activities. Mother slovenly,
indecent, filth}', uses tobacco and snuff to excess;
has severe eye trouble. The family lived in a one-
room “shack on wheels” which was moved from
place to place. The children had no schooling; no
training in personal cleanliness; lewd practices and
conversation were their con.stant portion. One older
brother was sent to Glenwood and one or two
smaller children left at home when these boys were
sent to Toledo. They were fairly well behaved, but
did not do very well in school work. They have now
been sent to Glenwood.
Family 4. These four children are quite intelli-
gent, child A having the second highest I. Q. of any
child in the home. Child C, with an I. Q. of .85,
and a mark of D in kindergarten work, seems to be
the least intelligent and one on whom another test is
indicated. No family history is available.
Family 7. These two boys are both feebleminded.
No family history is available. The oldest, having
an I. Q. of .45, speaks very indistinctly; has an ir-
regular pupil on the left; both pupils react, though
slowly, to light. The teeth appear normal, the palate
is high. Knee jerks diminished. He says his father
deserted the family. There are several suggestions
of congenital neuro-syphilis. The younger boy has
an I. Q. of .71, indistinct speech; normal pupils and
reflexes; high palate. His mental age is already
above that of the brother, although he is tw’O and
one-half years younger, so that, although feeble-
minded, he is less so than is the older child.
Family 9. The older boy has an I. Q. of .69, and
is certainly feebleminded. Nearly eleven, he is do-
ing well in second grade work. He has a high palate,
no other stigmata, no abnormalities in the neuro-
logical examination. The younger brother, with an
I. Q. of .80, is one and one-half j'ears retarded; do-
ing well in the first grade (eight years old). The
neurological findings are normal. He is probably
not feebleminded, though another examination next
year will be necessary to determine this. Of course,
the fact that one child in a family is feebleminded
and no adventitious disease is present to account for
it, makes us suspect that other children in the same
famil}' are also feebleminded, especially if they show
some retardation. To properh- discuss this point,
however, would lead us too far afield. It recurs con-
tinually in these family groups, and will not be
further discussed.
VoL. XII, No. 10]
Journal of Iowa State Medical Society
399
Family 11. The older boy seems normal in every
way. The younger lias an I. Q. of .87, no neurolog-
ical abnormalities; high arched palate; is doing well
in school, and is probably also normal.
Family 14. The older girl shows an I. Q. of .82,
cannot give her birth year, shows facial asymmetry,
rather limited grasp, high palate, cyanotic hands;
neurological examination normal. Although she has
missed school because of sickness, she is doing good
work in the fourth grade. Normal. The younger
girl is also normal and has a higher I. Q. than the
older sister.
Family 16. Both of these boys are feebleminded,
the older with an I. Q. of .64, the younger with an
I. Q. of .75.
Family 24. The ages of these four children are
not entirely certain, but are thought to be accurate.
The father is now in prison for burning his own
house. Both he and the mother are described as
“bad characters.” The oldest girl (eleven years,
three months) has an I. Q. of .98, learned much of
sex matters at home, still wets the bed at night, oc-
casionally walks in her sleep, has facial asymmetry,
cyanotic hands, an irregular pulse running 96 per
minute, enlargement of the thyroid, small, irregular
pupils which react well, e.xaggeration of the deep
reflexes. The findings strongly suggest hyperthy-
roidism. Child B, nine years and four months, has a
mental age of seven so that she is feebleminded if
the age is correct. She has scaphoid scapulje, fast
pulse, exaggerated reflexes, no thyroid enlargement,
normal pupils. Says she has periods of nervous-
ness. Child C, seven years, three months, with an
I. Q. of .76 is a border line case, possibly feeble-
minded. Child D has an I. Q. of .86 and is pre-
sumably normal. There are minor indications in this
family of possible congenital neurosyphilis.
Family 27. Children A, C and D are certainly
feebleminded, with I. Q. of .64, .73 and .78 respec-
tively. One older sister is probably also feeble-
minded.* They come from a very poor home, where
frank sexual promiscuity seems to have been the
rule. Child A has a definite hyperthyroidism. Chil-
dren C and D show various stigmata of degeneration.
These three children resemble each other very
closely, and are all perfect minatures of the ordinary
screen “vamp.” Child B differs greatly in appear-
ance from the others and is much brighter than they
(which she realizes). She is very quaint and precise
in her expressions. There is nothing of note in her
physical condition, except a very slight enlargement
of the thyroid. She is well behaved, an A student
in the fourth grade at the age of ten. She is, then,
the one normal child in the family.
Family 33. The mother of these children became
insane in 1919 (apparently an involutional psycho-
sis) and was committed to Cherokee. In 1920 the
father was sentenced to twenty-five years at Ana-
mosa for incest with a step-daughter (not one of
these children). All of the children seem to be
normal. Child A was somewhat sullen and defiant
the day of examination, which probably explains her
low record, as she gives a very intelligent account
of her family and herself. C and D are twins, girl
and boy, and are reversed in position on the Morgan
and Binet tests.
Family 43. The ages of these children are some-
what uncertain. A is certainly feebleminded; the
others are not, if their ages are reliable.
Family 45. Child A is certainly feebleminded,
with an I. Q. of .68. She shows strabismus, high
palate, normal reflexes. Child B is possibly feeble-
minded, and this must be determined by future tests.
Family 48. The record states that the father of
these children became insane and the mother re-
married. Child A says she was living with her
father and stepmother, that her father was cruel to
her and that he ran away. This girl gives a history
of fainting spells, of visions, of bad temper, etc.
There seems little doubt that she is feebleminded,
with many psychopathic traits and a stormy future
ahead of her. Child B is normal, child C is re-
tarded, and probably feebleminded.
Family 49. Both of these children are normal.
Family 51. These three are normal children, sent
to the home because of the father’s relations with
his housekeeper which led to his arrest and imprison-
ment.
Family 52. Both of these boys are normal.
Family 54. Child A is a squat, pallid girl, with en-
larged thyroid, slow pulse, diminished reflexes and
menstrual disturbances suggesting hyopthyroidism.
She was tested twice at four months interval, the
I. Q. rising from .72 to .74, so that the diagnosis
feeblemindedness is certain. B is almost certainly
feebleminded, C is probably normal.
Family 58. The mother of these boys was “un-
balanced” for thirteen years — “Talked to herself” —
“didn’t have good sense.” The father was lazy, shift-
less, heavily alcoholic. The probation officer has
“placed mother where she will be treated, found a
home for baby and sister and expect the family to
find itself eventually.” Child A is definitely feeble-
minded, with the fourth lowest I. Q. found in the
entire group. Child B, mental age eight, I. Q. .84, is
retarded and, in view of the history and his brother’s
rating, probably will turn out to be feebleminded
also.
Family 59. The parents of these children are di-
vorced. Child A insisted on living with the father,
though awarded to the mother. Child A is not fee-
bleminded. She gives a good history of herself.
There have been no sex experiences. She gives a
history of visions and occasional auditory illusions.
The left pupil is irregular; both react very slightly
and very slowly to light. Reflexes otherwise nor-
mal. Thyroid palpable, but no signs of hyperthy-
roidism. Child B is recorded as ten years of age,
but insists he is only eight. If the latter is true, he
is not feebleminded. His pupils are also slow, other
reflexes normal. In both cases there are definite
suggestions of congenital neurosyphilis.
Family 62. These are two of the brightest girls in
the school. The younger suffers from bitemporal
400
Journal of Iowa State Medical Society
[October, 1922
headaches such that she can attend school only one-
half day, yet she is doing A work in the fifth grade
at ten years. There are no abnormal phj-sical find-
ings in either.
Family 63. The father is a low grade laborer, the
mother shiftless and immoral. The three older chil-
dren are definitely feebleminded, the youngest is
probably so, as the chances are his mental age will
not continue to develop with his chronological age.
To determine this further observation and testing
will be necessar\-.
Famih’^ 64. The parents are divorced. The hand-
writing of the father suggests paresis. There are no
signs of neurosyphilis in the examination of the
children, both of whom are feebleminded.
Family 69. Neither of these children is feeble-
minded. A has the highest I. Q. found. The re-
tardation of B is excessive, and he may turn out to
have reached the limit of his mental development.
Family 70. The parents are divorced. The
mother deserted the children, who seem normal in
every way.
Famih' 71. Both of these children are feeble-
minded. One brother is in Glenwood. There are no
physical findings of significance.
Family 74. The father is very easy-going, a la-
borer. Mother died of cancer in 1920. The last
child is microcephalic. A and B are feebleminded
and show various stigmata; no abnormal neurologi-
cal signs. C and D, on the other hand, rate well on
the tests, and seem quite intelligent. One would like
to find some constitutional disease, such as syphilis,
which had affected the younger children less than
the older, to explain this condition, but there are no
indications that this is true.
Famih' 76. Child A is normal in every way.
Child B is definitely feebleminded, of bad conduct.
He shows no neurological or physical abnormalities,
beyond a very high palate.
Family 78. The father is dead. The mother de-
serted the children. The older three are apparently
normal, the youngest is retarded and will have to be
further observed.
Family 82. Both of these boj's we believe are not
feebleminded. Both lack schooling. The older boy
took a horse and buggy to go to his uncle’s, other-
wise conduct seems to have been good. No neu-
rological findings.
Family 84. Child A is definitely feebleminded.
Child B is more intelligent, and possibly normal,
though retarded.
Family 88. The girl is a very interesting case of
psychopathic personality, with manj- traits of de-
mentia praecox personality. We think these emo-
tional difficulties probably explain her low Binet
age. Her father is now a patient at Cherokee. She
shows marked tremor, thyroid enlargement, pulse
120, and other signs of hyperthyroidism. Treatment
should first be directed to that. The brother seems
normal.
Family 89. These two boys are somewhat re-
tarded, but probably normal.
Accordingly, of the eighty-five children in
these thirty-three families, we have twenty-nine
feebleminded ; seven retarded, possibly feeble-
minded ; ten retarded, probably normal ; one psy-
chopathic personality ; and thirty-eight normal,
while there is a question of congenital syphilis m
five ; hyperthyroidism in two ; possible hypothy-
roidism in one.
For the remaining fifty-six children the diag-
noses are as follows :
Feebleminded — No. 2, 5, 6, 13, 20, 30, 31, 32, 55, 61,
68, 73, 86, equals 13.
Retarded, probably feebleminded — No. 10, 12, 44,
60, 79, 87, equals 6.
Retarded, probably normal — No. 39, 57, 67, 77, 85,
equals 5.
Psychopathic personality^ — No. 8, 15, 18, 21, 38, 46,
56, equals 7.
Normal— No. 17, 19, 22, 23, 25, 26, 28, 29, 34, 35, 36,
37, 40, 41, 42, 47, 50, 53, 65, 66, 72, 75, 80, 81, 83,
equals 25.
Certain of these are sufficiently striking to
warrant brief notes.
No. 8. This girl of thirteen is a bold type, with
much sex knowledge, who, after the examination,
spread a story about that the doctor had asked her
some very vulgar questions. She was a runaway,
given to exaggeration; showed a tic involving the
eyelids; exaggerated reflexes; emotional instability.
Diagnosis: ps\-chopathic personality.
No. 15. A girl who previously suffered from
chorea; of cyclothymic makeup; without signs of
chorea or congenital neurosyphilis at the time of
examination. Psychopath of cj’clothymic type.
No. 18. Probably the most interesting of all the
cases. This girl of seventeen had been for three
years at St. ^lonica’s Home in Des Moines, and was
transferred because of her behavior. Tnere had
been some sex experience, for which she was ex-
treme!}' remorseful, feeling that it was a great sin
against God. She has cycles in which she acts very
badly, becomes very blue and after two or three
days ends up in an outburst of temper and violence.
Afterwards she is very sorry, “because it doesn’t
please God and will ruin me.’’ She is determined to
do what is right. Has felt that God has said things
to her, and has been very close to her, though she
never actually heard His voice. Has fainting spells
occasionally. Is tearful in telling of her wickedness
and how little she deserves. There is a “widow’s
peak’’ — growth of hair until it almost reaches eye-
brows on sides, a mongolian cast to the countenance.
Neurological examination negative. Intelligence
normal. Diagnosis: Psychopathic personality, un-
stable type. She has since been placed with a family,
where she is doing well.
No. 21. A very seclusive, indifferent girl of thir-
teen, who shows many characteristics of the de-
mentia praecox personality.
VoL. XII, No. 10]
Journal of Iowa State Medical Society
401
No. 31. A girl of si.xtcen, with I. Q. of .63, who
shows grimacing, nystagmus, stigmata of degenera-
tion, unequal pupils, which react well, peg-shaped
lateral incisors, palpable thyroid and rapid pulse, so
that the questions of congenital syphilis and hyper-
thyroidism is raised.
No. 32. In addition to low mental rating, pre-
sents typical picture of exophthalmic goitre.
No. 38. A boy whose mental rating is just above
the moron ‘level, who shows various traits, includ-
ing bestiality, to indicate psychopathic personality.
No. 46. An interesting case of hysterical type of
psychopathic personality, with spells suggesting
epilepsy.
No. 87. A probablj' feebleminded girl showing
enlarged thyroid, excessive pallor, fleshy, stolid in
type. Nystagmus, facial asymmetry; pupils and re-
flexes normal; the whole picture suggesting con-
genital lues or polyglandular dystrophy.
Discussion
It will be seen from the table and the discussion
of individual cases, that we divide the cases as
follows :
Feebleminded 42 = 29.7%
Retarded, probably feebleminded 13 = 9. %
Psychopathic personality 8 = 5.7%
Retarded, probably normal 15 = 10.6%
Normal 63 = 44.6%
Undoubtedly at first sight the percentage of
feeblemindedness seems high. However, we
would suggest that dependent and neglected chil-
dren are apt to be derived from those portions
of the population less endowed with intelligence,
and hence less fitted to maintain themselves in
the struggle for existence.
Taking together the feebleminded, probable
feebleminded and the psychopaths, we have a to-
tal of sixty-three cases, or 44.6 per cent that
present definite psychiatric problems. It must
also be remembered that in at least six cases there
is definite suspicion of congenital neurosyphilis,
and in six glandular disorder of one or other
type. All these are, strictly speaking, problems
for the physician and the expert in feebleminded-
ness rather than for the officers of a home such
as this.
To any one who has faced the problem of
training a group of children similar to those de-
scribed in this paper the value of such a survey
as that made at Toledo will be apparent. Those
in charge of such a home are responsible for the
training of these children in all fields. They not
only are recjuired to teach them academic sub-
jects, but must supervise character training and
physical development as well. Such responsibil-
ity cannot be faced without some scientific knowl-
edge of the material with which one has to deal.
Picture the turmoil with its consequent injustice
that is sure to result when congenital syphilitics,
endocrine disorders and other organic defects are
ignored. Because, perhaps, such children cannot
learn they are' thrown with the feebleminded.
These are all prodded with the ordinary academic
problems with no effect and are apt finally to be
given up as hopeless cases. To add to this con-
fusion the unrecognized psychopaths are punished
for breaches of conduct and the teachers grieve
that they have wasted all their energies trying to
give moral training to such undeserving or incor-
rigible children.
With the background of an adequate survey the
administrators of an institution can give medical
treatment to those cases needing it ; they can give
training suitable to the mental level of the dif-
ferent individuals instead of trying to teach them
subjects beyond their ability; they can. give the
psychopaths the attention and consideration that
they require and as a result can do vastly more
for the normal individuals who are thus freed
from the retarding and undesirable influence of
the subnormals and abnormals.
It would appear to us that the logical time to
determine whether the children are normal or
abnormal is before they are sent to the Home.
This would necessitate some sort of adequate in-
vestigative machinery in connection with the
courts dealing with these children ; a machinery
which now exists in only a few cities. No prob-
lem is of greater importance than just this one;
the proper training of children, — training which
can properly only be given when all the limita-
tions of the individual child have been subjected
to careful analysis from every possible point of
view. Such studies will yield returns economic-
ally, socially, and for the individual to an extent
not ordinarily recognized. They will help to re-
place our trial-and-error methods with those more
scientific, and hence more humane.
402
Journal of Iowa State Medical Society
TABLE I
[October, 1922
A summary of the findings in each individual case.
Explanation of abbreviations under conduct: E, excellent; G, good, F, fair; B, bad.
The number given refers to the family name, the letter to the individual child. In case there is no
letter it means of course that there is only one child of that family at the school.
Other abbreviations are self-explanatory.
la
SEX
F
AGE
Yrs. Mos.
12 9
Morgan Morgan
Score Rating
47 C
BINET
Yrs. Mos.
IQ.
SCHOOL REPORT
Grade Mark Conduct
DIAGNOSIS
Normal
lb
M
11
7
9
".70
Feebleminded
2
F
7
6
.87
K
A
E
Feebleminded
3a
13
9
1
7
.51
2
C
G
Feebleminded
3b
M
11
1
0
6
9
.61
2
C
E
Feebleminded
3c
M
8
5
6
.69
1
D
F
Feebleminded
4a
IM
14
10
16
4
1. 10
Normal
4b
F
13
7
13
.95
'8
B
G
Normal
4c
F
7
4
6
'3
.85
1
C
G
Normal
4d
F
5
2
5
3
1.01
K
D
G
Normal
5
M
10
7
.70
1
F
F
Feebleminded
6
13
7
10
.79
Feebleminded
7a
M
9
4
4
3
.45
K
D
F
Feebleminded
7b
M
6
9
4
9
.71
K
C
F
Feebleminded
8
F
13
6
10
10
8
.79
4
B
G
Psycho. Personality
9a
M
10
11
7
6
.69
2
A
F
Feebleminded
9b
M
8
2
6
6
.83
1
B—
G
Probably Normal
10
F
8
2
6
9
.80
Probably Feebleminded
11a
M
* 12
11
39
C
12
4
.95
6
C
F
Normal
11b
Jil
10
2
8
9
.87
4
A
E
Probably Normal
12
M
11
27
C
Probabl}" Feebleminded
13
M
5
6
3
9
.68
K
D
F
Feebleminded
14a
F
11
5
20
D
9
4
.82
4
A
E
Normal
14b
F
5
6
5
9
1.04
K
A
G
Normal
15
F
15
10
69
C-F
8
B
C
Psycho. Personality
16a
M
10
2
6
6
.64
1
B
G
Feebleminded
16b
U
8
3
6
3
.75
1
C
F
Probably Feebleminded
17
M
13
8
55
C
6
C
F
Normal
18
F
17
4
95
B
14
11
.86
Psycho. Personality
19
F
11
8
40
C
5
c
F
Normal
20
M
13
8
8
9
1
.67
4
B
F
Feebleminded
21
F
13
3
53
C
8
C
G
Psycho. Personality
22
M
11
9
11
6
.98
6
C
G
Normal
23
'SI
10
11
11
5
B
G
Normal
24a
F
11
3
35
C
11
.98
5
c+
E
Hyperthyroidism (?) Lues
24b
F
9
4
7
.75
3
c
E
Probably Feebleminded
24c
M
7
3
5
'6
.76
K
B
F
Probably Normal
24d
M
4
11
4
3
.86
K
C
F
Probably Normal
25
M
13
7
48
C
12
8
.93
6
B
G
Normal
26
F
8
8
8
4
A
E
Normal
27a
F
11
2
1
7
3
.64
2
D
G
Feebleminded Hyper.
27b
F
10
1
28
C
9
3
.93
4
A
E
Normal
27c
F
9
6
9
.73
1
C
F
Feebleminded
27d
F
8
4
6
6
.78
1
C+
F
Feebleminded
28
F
6
7
6
9
1.02
K
B
F
Normal
29
M
9
10
9
1.00
, .
Normal
30
M
14
13
8
3
.59
4
D
F
Feebleminded
31
F
16
2
54
C
10
1
.63
6
B
E
Fm. Hyper. (?) Lues
32
F
14
4
11
8
6
.59
4
A
G
Feebleminded Hyper.
33a
F
15
5
45
C
11
7
.76
8
B
E
Probably Normal
33b
F
13
2
82
c+
15
1.11
7
A
G
Normal
33c
F
11
7
32
c
11
'6
.99
5
B
G
Normal
33d
M
11
7
40
c
11
.95
5
B
G
Normal
VoL. XII, No. 10]
Journal of Iowa State Medical Society
403
34
SEX
AI
AGE
Yrs. Mos.
12 2
Morgan Morgan
Score Rating
64 C
BINET
Yrs. Mos.
I.Q.
SCHOOL REPORT
Grade Mark Conduct
7 B F
DIAGNOSIS
Normal
35
F
11?
9
29
C
4
A
F
Normal
36
M
7
11
7
9
.98
3
A
E
Normal
37
F
14
12
8
.91
7
B
G
Normal
38
M
16
1
57
C
12
4
.77
6
C
F
Psycho. Personality
39
F
15
11
71
C+
12
.75
Probably Normal
40
F
13
4
51
c
7
c+
F
Normal
41
F
14
8
13
3
.90
7
B
E
Normal
42
M
13
3
52
c
7
c+
F
Normal
43a
M
12
3
2
8
3
.67
4
c
E
b'cebleminded
43b
M
9?
8
6
.95
Probably Feebleminded
43 c
M
6?
5
6
.92
k
B
G
Probably Feebleminded
44
M
12
6
14
9
6
.76
5
B
F
Probably Feebleminded
45a
M
12
1
7
8
3
.68
3
A
E
Feebleminded
45b
F
9
7
6
7
9
.81
3
A
E
Normal
46
F
15
9
13
.83
8
c+
G
Psycho. Personality
47
M
11
8
11
.94
6
B
G
Normal
48a
F
14?
69
C+
11
7
c+
F
Feebleminded
48b
M
10
4
11
1.07
4
A
E
Normal
48c
M
9
3
7
.77
4
A
G
Probably Feebleminded
49a
M
11
6
9
10
.85
4
A
F
Normal
49b
M
10
8
3
.83
4
A
F
Normal
50
M
14
5
54
c
5
B
G
Normal
51a
F
13
3
44
c
12
6
.94
6
c+
E
Normal
51b
F
12
55
c
11
6
.96
5
c
F
Normal
51c
F
8
'?
8
9
1.02
3
c
G
Normal
52a
13
72
c
7
C+
F
Normal
52b
F
9
6
'9
‘.’95
4
B
G
Normal
53
M
13
2
57
c
5
B
F
Normal
54a
F
11
6
9
8
3
.72
2
c+
G
Feebleminded
54b
F
10
7
9
.79
1
c+
G
Feebleminded
54c
F
6
4
6
3
.96
K
C+
G
Probably Feebleminded
55
M
11
10
8
6
.77
4
E
B
Feebleminded
56
F
14
2
49
c
6
C+
F
Psycho. Personality
57
M
10
1
9
.89
3
Fail
B
Normal
58a
M
13
11
0
7
12
. 56
3
B
E
Feebleminded
58b
U
9
6
1
8
.84
3
A
E
Probably Feebleminded
59a
F
14
3
55
c
7
c+
F
Normal
59b
M
10
'7
”.76
2
A
B
Feebleminded
60
U
11
1
24
D
5
C
F
Probably Feebleminded
61
M
11
1
7
6
.68
3
D
E
Feebleminded
62a
F
12
9
99
B
14
1.09
7
A
G
Normal
62b
F
10
8
10
5
.95
5
A
G
Normal
63a
F
15
9
8
1
.50
4
B
E
Feebleminded
63b
M
13
5
9
.66
3
B
E
Feebleminded
63 c
F
10
8
7
3
.68
2
c+
F
Feebleminded
63d
M
7
2
6
6
.90
1
D
F
Normal
64 a
F
10
4
3
8
.77
3
D
F
Feebleminded
64b
F
8
7
7
.81
3
D
G
Normal
65
AI
13
7
40
c
5
c+
F
Normal
66
F
11
7
12
1.03
7
B
G
Normal
67
M
6
5
.83
K
c+
G
Probably Normal
68
M
13
9
8
6
.62
5
D+
F
Feebleminded
69a
M
15
1
18
1.20
7
B
G
Normal
69b
F
11
4
9
’3
.81
5
C
F
Probably Normal
70a
F
14
2
13
7
.96
9
B
G
Normal
70b
F
9
6
47
c
11
1.16
5
B
G
Normal
71a
M
10
7
8
3
.78
3
B
E
Feebleminded
71b
F
8
4
6
3
.75
1
C
G
Feebleminded
404
Journal of Iowa State Medical Society
[October, 1922
72
SEX
U
AGE
Yrs. Mos.
7 ..
Morgan Morgan
Score Rating
BINET
Yrs. Mos.
6 6
IQ.
.94
SCHOOL REPORT
Grade Mark Conduct
1 C-F G
DIAGNOSIS
Normal
73
M
14
7
1
7
9
.53
Feebleminded
74a
U
14
3
21
D
9
.64
6
C
E
Feebleminded
74b
M
F3
29
C
9
6
.72
5
B
G
Feebleminded
74c
11
5
48
C
12
1.05
6
c+
G
Normal
74d
F
8
7
8
3
.96
3
A
E
Normal
75
F
14
8
60
C
6
c+
F
Normal
76a
M
12
3
13
1.06
6
B
G
Normal
76b
M
6
3
9
.65
K
C
B
Feebleminded
77
F
14
7
40
C
11
4
.77
7
B
G
Probably Normal
78a
F
12
7
42
C
12
11
1.02
5
c+
E
Normal
78b
F
10
8
6
.85
3
B
E
Normal
78c
M
M
8
6
8
.94
2
B
G
Normal
78d
6
1
4
6
.74
K
C-F
G
Probably Normal
79
M
8
7
6
9
.78
2
B
G
Probably Feebleminded
80
F
15
73
C
8
B
E
Normal
81
F
14
2
82
C
....
9
B
E
Normal
82a
M
13
24
D
io
"96
4
A
G
Probably Normal
82 b
M
11
16
D
4
B
G
Probably Normal
83
F
13
7
13
.96
6
B
G
Normal
84a
M
11
6
1
7
6
.65
3
D
G
Feebleminded
84b
M
8
9
7
9
.87
3
D
G
Probably Feebleminded
85
M
9
2
7
9
.86
Probably Normal
86
M
14
6
3
8
6
.58
4
B
E
Feebleminded
87
F
9
10
7
9
.79
3
B
B
Prob. Fm. Gland Dys.
88a
F
13
8
67
10
6
.75
6
c+
G
Psycho. Person. Hyper.
88b
M
8
8
3
1.03
3
A
G
Normal
89a
M
8
2
7
3
.88
1
c+
F
Normal
89b
M
6
8
5
6
.83
K
c
F
Normal
THE TREATMENT OF FRACTURES*
O. C. iMoRRisoN, M.D., Carroll
A patient presenting a fracture should be
looked over very carefully. In case he has sus-
tained a simple Codes, while cranking a car, or
the fracture of a finger or of the bones of the leg
or foot by a direct blow, it is easy to determine
the character of the injury sustained. In case of
auto accidents, or where the patient is thrown
with violence or is crushed or hit by a large body
traveling at a great velocity, as in railway in-
juries, we are presented with a different problem.
We can easily determine that a man who has
fallen off a barn, windmill or smoke stack, has a
fractured arm or leg, but this same patient may
be unconscious, he may have extensive flesh
wounds and have shock so severe that death
seems imminent at any hour. Under these cir-
cumstances we ask ourselves, “What shall we do
first?” We wonder if he has a fractured skull,
or if he has an open vessel that is responsible
for compressing the brain tissues. Has he a de-
pressed fracture, is the liver, the spleen, or other
•Presented before the Austin Flint-Cedar Valley Medical Asso-
ciation, Clear Lake, Iowa, July 20, 1921.
viscus torn or ruptured, is his bladder intact?
Under these circumstances a fracture of the long
bones is a negligible thing in comparison. He
may have, along with any of these, a compound
fracture of the femur. I recall a case that had
both legs, one arm and his back broken by dirt
falling from a height striking him across the
shoulders and crushing him. Yet he is alive after
seven years. I bring this picture to your atten-
tion to show you that we must meet the most se-
riously threatening symptoms first, and eliminate
them in order until we have cared for every one
that is responsible for any pathology in the pa-
tient injured. We may find it is necessary to
let the fracture of a long bone go for several days
until conditions are suited to its care.
Shock — I feel that we should consider shock as
one symptom accompanying all fractures. We
seldom get a fracture of any bone that the symp-
tom of shock is not manifest. It may be slight in
severe injuries, it may be out of all proportion in
slight injuries. We do not know what shock is.
It is like electricity. We know where it is, es-
pecially -when we get into contact with it for the
first time. In severe injuries it is very hard to
know which irritation area is responsible for it.
VoL. XII, No. 10]
Journal of Iowa State Medical Society
405
In injuries about the head with concussion of the
brain, we may have extreme shock, again with the
severest forms of skull and brain injuries. Com-
pression may cover it so completely that the pulse
will be thirty or forty instead of 160 or higher.
If the patient has injuries of the abdominal vis-
cera he should be observed by the most experi-
enced surgeon procurable. It is not within the
scope of this paper to go into the details con-
cerning visceral injuries complicating fractures
causing shock but we are ofttimes delayed waiting
for these symptoms to abate before we proceed
with our fracture work. The shock from the
fracture of the humerus or femur may be fatal
of itself. I recall an old lady who sustained a
comminuted fracture of the left humeral head
and neck, the shock threatened her life for many
hours. In fracture of the pelvis, vertebra or
skull, it may mean the exitus of your patient un-
less you are successful in combatting it. When
it is severe, it is best to care for it alone allowing
all else to wait until this danger is averted and
the shock period is passed. We care for the
broken limb or bone in a palliative way during
this period.
X-Ray — If the condition of the patient will
permit we should have a carefully planned x-ray
examination of every area which we suspect may
have a fracture or dislocation.
The x-ray is indispensable in the treatment of
fractures. It is an instrument of precision and
should be used only by those who understand its
use and are acquainted with its interpretations.
Every fracture should be rayed in at least two
planes. In many fractures the use of a plate of
one plane only is worthless and misleading as I
will show you in the slides. From the plates you
learn the type and extent of fracture and the re-
lationship of the fractured ends. It tells if the
bone is comminuted or not as this is important in
the treatment. The x-ray plate may be very mis-
leading in children as the uncalsified cartilage
may be badly separated and not show, especially
in elbow injuries. Exeprience is the best guide.
Fractures of the vault and base of the skull are
usually depicted by a well planned plate. Your
plate will serve you in a wonderfully intelligent
manner if it may, and it is worse than useless to
the ignorant and inexperienced. I recall one case
in which the acetabulum has been divided; the
pubic and ischi arches were fractured through the
obturater foramen and the head of the femur was
in the abdomen and after several plates, in the
hands of the inexperienced had been made, this
woman was allowed to be up to the slop jar sev-
eral times a day and was thought to have a
sprained hip. I do not mention this to belittle,
but to call attention to the fact that the x-ray is
your auxiliary. You, not the machine, are to
possess the intelligence. The best x-ray machine
and technician should always be at hand. Poor,
cheap machines give poor, inferior plates and in
fractures, are too often the basis of damage suits.
If each physician who has to do with fractures
would insist on good first class x-ray work and
would accept nothing else and follow this by in-
telligent treatment of the fracture, damage suits
would become so infrequent as to be almost neg-
ligible. If a patient refuses to have plates made,
and to co-operate with you, it is a danger signal
to be interpreted to mean that a damage suit is
already brewing in the mind of the patient and
you should feel that you are better off, both men-
tally and financially when you tell him to go
somewhere else to get the services he wants. Per-
sonally, I refuse to treat a patient if I cannot do
as I feel will be to his best interest. The golden
rule will well apply.
I always have the x-ray plate before I attempt
reduction, then the reduction, the cast or dress-
ing, and another plate to see the result of my
work, and then another plate when all dressings
and casts are removed and the patient is to leave
my observation. I record all dates and treat ev-
ery fracture with the precision of expecting to
appear in court on the morrow and give an ac-
count of every step in my treatment. I keep a
constant vigilence over fractures that do not cal-
cify in the time I think they should and in those
cases Wassermanns are made.
Treatment — In the treatment of fractures the
results obtained depend far more upon who is to
treat the fracture than upon any specified plan
of procedure. In other words, no set plan will
give you good results in all cases, even in the
same type of fracture. It is necessary for the
surgeon to be able to improvise a plan that will
give him a good result in the case at hand. He
should possess sufficient tact that a good result
will reward his efforts and the patient will be
well satisfied. The psychology of the patient
must be taken into consideration. Before begin-
ning the treatment of a fracture, one looks the
situation over carefully from every viewpoint and
then selects the treatment that will assure a good
result for the patient and leave him 100 per cent
happy. The patient’s environment, his mental at-
titude and the influence of his friends may influ-
ence your plan of treatment materially. Other in-
juries sustained at the time of the fracture may
cause you to adopt a plan entirely foreign to your
custom, but your judgment will best serve you
*406
Journal of Iowa State Medical Society
[October, 1922
under these circumstances. One is always anx-
ious to know what plan has been used to immo-
bilize the fractured bone while in transit to the
scene of treatment. Did those who brought him
to you allow the leg to dangle over the edge of the
auto seat or the end of a board and do irrepara-
ble damage to muscles, tendons, nerves or vessels
before you even had an opportunity to have one
word in directing his treatment? In compound
fractures one is anxious to know if they have had
a spider web poultice on the wound to stop the
bleeding, or a dozen cuds of tobacco from twelve
mouths advanced in bacterial growth of pyorrhea
or other infections. We are anxious to know if a
constricting bandage was applied so long as to
disturb the circulation of the part, or if there has
been sufficient hemorrhage in non-compound
fractures to disturb the circulation to the overly-
ing muscles and have surgical acidosis supervene
as a reward.
Our part as surgeons in fractures has to do
with the proper management of the case to get
the best possible repair in the bone. Our treat-
ment naturally falls into two groups ; operative
and non-operative.
The non-operative fractures are those in which
you can get a satisfactory result without opening
the fracture in an operative procedure. Any bone
at any site may be fractured and a perfectly sat-
isfactory result obtained, again any bone at an}-
site may be so fractured that the ingenuity of the
most experienced and highly skilled may find
great difficulty in getting a good result. We may
say in a rough way, that such bones as the scapula,
clavicle, sternum, ribs, pelvis, small bones of the
hands and fingers, feet and toes do not require
the so-called open plan. All have their excep-
tions. Did you ever have a fracture, dislocation
of the carpus? The simple easy fractures, those
that can be easily reduced and little trouble ex-
perienced in maintaining the fragments in posi-
tion should not worry any experienced surgeon
and we shall devote little attention to this class of
cases. X-ray, cast and good aftercare gives you
the result you desire.
The cases that give you the trouble are :
1 . Cases in which you cannot get proper appo-
sition by external manipulation.
2. Those in which you cannot maintain proper
apposition after reduction.
3. Compound fractures.
4. Fractures where injury has occurred to the
surrounding structures and that require surgical
care.
Group I. In discussing a plan for the care of
apposition we consider all long bones as belonging
to this class. Any of them may have muscle or
fascia interposed preventing apposition, or they
may be difficult to appose due to their overlying
muscles or to their interbony relationship of which
carpus is a good example.
One is surprised at the number of fractures of
both humerus and femur in which the ends are
wrapped with muscle tissue. The care of de-
pressed skull fractures, fractures of the malar
bone, vertebra, head of the humerus and femur,
patella and many other bones, fall into this group.
Group 2. Fractures that require fixation to
hold them in position are those upon which we
most often operate or use some form of internal
splint or fixation. To this group belong the
lower jaw fractures, certain types of fractures of
all long bones, especially the humerus, femur,
bones of the forearm, carpus, astragalus, oscalcis,
horizontal fractures of the patella, in fact most
bones may be subject to this classification. The
femur, humerus and both bones of the forearm
are perhaps best suited and require the open
method more often than any other bones. They
are exposed to traumatism more because of func-
tion and position, and for these reasons we must
be assured of as nearly a perfect a result as is
possible. There are many plans of the applica-
tion of the principles of internal splints or the
open method. Each orthopedic worker has pop-
ularized a plan and feels that his plan is superior
and can be used in all cases. Those of you who
have had a broad experience know that you fit a
method to the case and not try to fit all cases to
one method. In our own work we find many
fractures that can be treated with plates and
screws. Some of the spiral and long fissured
fractures are best suited to the Parham-Martin
band. I have used the sliding graft in some and
the bone plug in others.
The Lane’s plate has been used most exten-
sively by us and has without exception measured
up to our expectations. There is no reason why
it will not serve any competent surgeon if he will
develop the technique sufficiently accurately to
do the work. I have gone one step beyond all
expectations and made use of it (Lane’s plate) in
extreme cases of compound infected femur and
tibias, humerus and forearm ; in fact anywhere.
I have no reason to doubt its usefulness and it is
responsible for many excellent results for me
where other methods had failed. (I shall show
you the results in the lantern slides.)
Group ?. This brings us to the compound
fractures. This class of fractures taxes the in-
genuity of the most experienced surgeons. No
plan will serve all cases. Again, the ability of
VoL. XII, No. 10]
loUK.vAi, OF Iowa State Medical Society
407
the surgeon must demonstrate a plan that is effi-
cient. Many plans of treatment have been in-
stituted. The Balkan frame was made use of
especially for this class of cases during the war
with excellent results. Personally I open every
case of compound fracture and do what to me
seems indicated.
The plan of treatment I have given you permits
you to look after the fourth classification or the
injured tendons, muscles, nerves and vessels. 1
never hesitate to open a fracture anywhere in the
body if I feel that it should be done. If you have
a depressed fracture of the skull it requires the
open treatment, or if the brain is compressed by
hemorrhage, or the cord is similarity affected, it
may require a laminectomy by the open method.
Case Records of Fractures
There is no class of patients where a carefully
kept record is so essential.
You will find it very interesting to take the
entire history as a routine, like all other routine
examination of cases and include carefully, all the
history of the injury, which was responsible for
the fracture. The patient will appreciate the in-
terest you take in him and you increase his confi-
dence in your work. You will often gather in-
formation that will be of untold value to you in
your treatment. Suppose he is suffering from
lukemia, anemia of the so-called pernicious type,
nutritive disturbances or is a case of lues, etc.,
you will be very liable to unearth these facts and
gather them into your data. I well remember a
case of ununited fracture of the tibia, of one year
standing. I worked him out carefully and set-
tled all the controversy by giving the patient the
salvarsan I felt was due him and he had an ex-
cellent result.
Keep the dates of the dressings, x-ray plates,
history, physical findings and laboratory work, as
it will be valuable to you as a guide in your treat-
ment and may be an appreciated breastwork
of defense in case of trouble with malpractice.
Your follow up notes should be carefully re-
corded and be sure to have a blood count, urinaly-
sis and an x-ray plate on the day you dismiss the
case, as well as on the day you get him. In com-
pound fractures this data is indispensible. Your
only guide for amputation in many cases of com-
pound fracture is the secondary changes in kid-
ney, liver and glandular destruction due to
chronic sepsis. You should amputate before these
changes come, not after. Before you have kid-
ney changes suggestive of a nephritis and chronic
sepsis is marked, save the patient from having
crippled kidneys and distorted glandular function.
Every case of fracture should have a case rec-
ord of which you will be jiroud in any court of
aiqieal. Prejiaredness and a “watchful waiting,”
often calls a bluff even in medicine and surgery.
If case records were so made in all cases and the
work so done, 98 jier cent of damage suits would
be averted and fractures would be considered
things of intense interest.
Resume
In the treatment of fractures, I have discussed
no particular plan. The literature is full of plans.
Every orthopedist of great reputation feels that
he has a plan that fits any case. A few weeks
ago I saw a man demonstrate the Balkan frame
and he said that a Codes’ could be treated in the
frame with excellent results, but who wants to be
in a Balkan frame for a Codes’. Every plan may
serve you in certain cases. Your intelligence is
your guide. You have a large .storehouse of plans
and methods going back beyond the Balkan
frames. Thomas splints, .Sayers plans, etc.
Hipocrates had many plans of treatment. The
surgeons in the army of Israel had many plans
and one of the commentaries goes back to the
early days of the Hindu and Chinese literature
and .says they used every principle of the Thomas
and Hodgus splint and Balkan frame seven thou-
sand years ago. But back of all this, in the be-
ginning, man was given intelligence and was ex-
pected to use it and select the best from every
great plan that it may serve his purpose for the
good of humanity.
A BRIEE HISTORY OF PUBLIC HEALTFI
MOVEMENT*
Lena A. Beach, M.D., Rockwell City
When we speak of public health three subjects
at once present themselves before us : sanitation,
hygiene and preventive medicine. These are di-
vided and subdivided until they form one great
grand net work which involves the welfare of
men, women and children.
In looking over the history regarding public
health, it is difficult to tell when the idea first
originated, as we find the germ spreading through
many years in an obscure way.
In 1849 a great cholera scourge swept over
England. The clergy went to the prime minister
asking him to set aside a national day of fasting
and prayer. His reply was to the effect that
they should go back and clean up their homes,
cities, and then ask God to bless their efforts, to
*Address before State Society Iowa Medical Women.
408
Journal of Iowa State Medical Society
[October, 1922
rid themselves of the pestilence. This created
considerable comment, as it was looked upon as
sacrilegious, accordingly a day of fasting and
prayer was set aside and observed by the
churches, but the cholera continued to rage. One
little community took the statement literally,
cleaned tip their homes, and village and appointed
a “vigilance committee” to carry on the work.
They not only did not have a case of cholera but
found a lessening of other diseases. This at-
tracted notice throughout the countr)'^ and set
people to thinking more definitely along sanitary
lines.
The early thought in all public health work,
was to protect the sound from the sick, and little
thought was given to the individual suffering
from disease. Our first hospitals were estab-
lished by individuals and associations, and in ev-
ery country' the government has been the last *:o
take up this very important side of the situation.
As might be expected, the European countries
have taken the lead in priority in the great public
health movements. In the European countries,
health work has come largely under the control
of the government. The officers in this line of
work have nearly all had special training.
In our own country, the progress has not been
quite so rapid, due to political influence or con-
trol over public health officials, the lack of
knowledge of the people and hence of the gov-
ernment, in the true value of life and healtli.
Lord Beaconfield’s saying “that public health is
the foundation on which rests the happiness of
the people, and the power of the country ; the
care of the public health is the first duty of the
stateman” seems to not be comprehended in its
full significance. Our government has conserved
our rivers, our forests, our mineral lands and ani-
mals with more care than they have the human
life. These things are all essentials but should
stand second, rather than first, in consideration.
The health of man should stand first, if we are
to have a strong thinking nation. It was demon-
strated in 1915 by Professor Irving Fisher and
others, that in the United States approximately
3,000,000 people are constantly sick, at least one-
third of whom are in the working period of life.
“Dr. Joseph S. Neff makes the following deduc-
tion, allowing for the non-employment of one
quarter of these, and assuming the average an-
nual earnings to be $700, we find over $500,000,-
000 to be the minimum loss of wages, in addition
to which the cost of medical attendance and
nursing must be added ; an annual loss to the
nation of great magnitude. As public health is
not considered from a commercial standpoint, it
has not so readily obtained appropriations from
city, state or government sources.
As our cities have grown, population increased,
diseases carried by immigration more attention
has been given to this important subject and some
splendid work has been done by our country. Ev-
ery year finds us more alive to the great prob-
lems before us. In 1863-4 an epidemic of ty-
phoid fever raged in this countrjL Dr. Stephen
.Smith of New York tells us that while working
in a hospital he noted the number of cases that
came from a single house, he visited the home,
and found it “a filthy, deserted building, the
resort of immigrant families.” The attempt to
close the house revealed the fact that there was
neither law, ordinance, or force of any legal kind,
adequate to do it. When these facts became
known it led to a “Citizens Association” under-
taking to secure health laws. The final outcome
was the enactment of the metropolitan health
law, in 1886. This law gave unlimited authority
to the health officers and forbade court proceed-
ings delaying or obstructing its abatement of
nuisances. The legislature restricted its expendi-
tures to $50,000 annually. In 1915, they were
freely giving $4,000,000 for the work. The death
rate in New York showed a remarkable decrease
as the result of the labors.
The Public Health Service of the United States
dates back to 1796, when steps were taken for pro-
viding medical and surgical relief to merchant
seamen. At first, this was financed by a per capita
tax, collected from the seamen, the funds being
handled by the collectors of custom in the various
ports. Subsequently, this was changed into a
tonnage tax, collected through the same channels.
This explains why the marine hospital work (the
precedent of the present United States Public
Health Service) came to be lodged in the treasury
department, for the collections of customs was
naturally a growth of the American IMerchant
IMarine in the first half of the nineteenth centurv,
this method of providing for the merchant marine
was found to be inadequate, and the government,
therefore, established “marine hospitals” at va-
rious important points.
In an effort to guard against the introduction
of dangerous pestilential diseases from without,
it was natural that the officers of the marine
hospitals, stationed as they were at the important
ports of entry, should come into close relation and
take an active interest in marine quarantine mat-
ters. In addition to this, the repeated introduc-
tion of yellow fever into the southern states, and
the alarm occasioned thereby, caused repeated
calls to be addressed to the federal government
VoL. XII, No. 10]
Journal of Iowa State Medical Society
409
to take charge of control measures at the in-
fected points, in order to prevent the spread of
disease to other parts of the United States.
There being no special federal health agency,
these calls were naturally referred to the United
States Marine Hospital Service. More and more,
therefore, this service began to undertake federal
public health activities, a fact which was recog-
nized by Congress, when, in 1902, it changed the
name of the Service to the United States Public
Health Service and Marine Hospital Service.
More recently still, in 1912, the name was still
further changed to its present designation,
namely, the United States Public Health Service.
The United States Public Health Service is a
bureau in the treasury department. At its head
is the surgeon general. He is assisted by a staff
of assistant surgeon generals. Most of these
have charge of important functional divisions.
As at present organized, the work is carried on
under the following divisions :
Division of personnel and accounts.
Division of marine hospital. (In addition to
caring for merchant seamen, this division has
charge of all the medical and surgical relief work
for discharged soldiers, sailors, marines and
nurses, who are beneficiaries under war risk in-
surance act.)
Division of domestic quarantine. (This con-
trols the important field relating to the control
of disease through interstate traffic.)
Division of scientific research. (This is a
large division engaged in studying the diseases of
men through field investigations and laboratory
work.)
Division of sanitary reports and statistics.
(This division collects information regarding the
prevalence of communicable diseases, dissemi-
nates it through publications and otherwise lO
health officers and sanitariums throughout the
countr}\)
Division of venereal diseases. (This recently
granted division was established by Congress pri-
marily to safeguard the nation’s manhood against
the ravages of venereal infection.)
Section of public health education. (A re-
cently established activity for promoting public
health through popular health education.)
The great World War from which we are
realizing the after effects, has led the Public
Health Service to establish a special program to
care for what seems to be the live problems of
the day, briefly it is as follows :
Industrial Hygiene.
Rural Hygiene.
Prevention of the Diseases of Infancy and Child-
"hood.
Water Supplies.
]\Ialaria.
Venereal Diseases.
Tuberculosis.
Railroad Sanitation.
^lunicipal Sanitation.
Health Standards.
Health Education.
Collecting of ilorbidity Reports.
Organizing and Training of Duty in Emergency
of the Reserve of the Public Health Service.
The State Public Health Department in many
states is doing most excellent work, but I am go-
ing to confine my remarks to some of the things
being done in Iowa.
The Iowa State Board of Health was organized
in 1880. It was composed of seven physicians,
and a civil engineer, appointed by the governor
and serving seven years each. There being one
member retiring each year, and a new one ap-
pointed. The attorney general and the state vet-
erinarian were also members of the board. The
secretary was elected by the board and was not a
member. He had no power to do anything ex-
cept as he was directed by the board in session.
There was no change in the above until the
Thirty-fifth General Assembly. The law was
changed as follows. The governor, secretary of
state, auditor of state, and treasurer of state
should all be ex-officio members of the State
Board of Health. All funds to be expended un-
der the supervision and sanction of the executive
council. The governor of the state, the secretary
of state, and auditor of state to be an appointing
board, and the secretary of the executive council
is the secretary thereof. The appointing board
appoints five members of the board which con-
sists of four physicians and a sanitary engineer.
Of the four physicians not more than two shall
belong to the same school of practice. Of the
five no more than three shall belong to the same
political party. W’hen the board of health is not
in session the secretary, by law, is the state health
commissioner and the health officer of the board,
and has full power to act in the same manner as
the board would have when in session. This law
provides that an efficient member may be re-ap-
pointed.
The board of health acts on all the examining
boards pertaining to medical subjects, generally
one or two additional members being appointed
for the subject being considered.
The sanitary conditions of the state are being
improved under the board, health bulletins are is-
sued, vital statistics kept. A board of health lab-
410
Journal of Iowa State Medical Society
oratory was established some years ago in connec-
tion with the board of health. This is located at
Iowa City and under Dr. Henry xA.lbert, bacter-
iologist. Here physicians of the state may have
free examinations of bacteriological specimens
and Wassermann reactions. Patients who have
been bitten by rabid animals are treated here bv
the Pasteur method, free of charge.
Medicines for the treatment of infectious dis-
eases may be secured through the board of
health at a much more reasonable price than
elsewhere. During the past year a state lecturer,
Dr. Jeannette Throckmorton, has been sent out
under the board of health to discuss health prob-
lems with the women and girls of our state. She
has lectured in 112 towns and cities and delivered
over 500 lectures, reached 91,000 women and
girls. This is a splendid line and should be car-
ried on until teachers are prepared to teach these
things and health problems are a part of the
school and college curriculum. The State of
Iowa appropriates thirteen mills each year for
the health of each person of the state. Not much
value placed on a human life, is it?
Is it not time that the saving of human life
have a department of its own, instead of being a
division of the treasury department? The state,
national and community health officers should be
especially trained for their work.
Politics should play no part in their appoint-
ment, it should be a matter of qualification and
only resignation, inefficiency, and death should
terminate their tenure of office. The remunera-
tion should be sufficient to interest bright active
individuals in preparing themselves. Several of
our colleges and universities are now offering
courses and conferring degrees.
Of each hundred dollars spent by our govern-
ment during 1920, only one dollar went to public
health, agriculture, and education — just one per
cent for life, living conditions and national prog-
ress.
W’e must do much in community education.
W hen people understand the causes of disease
and how to prevent it, then we may hope to at-
tain the maximum health of each individual of
the community.
Time does not permit me to mention the indi-
viduals and associations which have been so ac-
tive in promoting the worthy movement. I trust
that by thus briefly reviewing the history of this
movement, I have been able to make you think of
the great work which has been done, and, most of
all, of the greater things which are still to be
done and which will be considered more in de-
tail during this meeting.
[October, 1922
RENAL FUNCTION TESTS IN CHRONIC
NEPHRITIS*
F. H. Lamb, IM.D., Davenport
The functional test of an organ contemplates
a measurement of that organ’s efficiency. It is
intended to show, in a more or less mechanical
way, the capacity of that organ to perform its
work. The nature of these examinations varies
quite as much as do the functions of the organs
and systems to be tested. For example, a most
valuable functional test of the heart may be car-
ried out by simply noting the effect of muscular
exertion on the cardiac and respiratory rate. On
the other hand, a functional test of the thyroid
gland may, in many instances, necessitate a com-
plete and rather complicated basal metabolism de-
termination.
Inasmuch as the kidney is an organ whose
function is purely excretory its functional ca-
pacity may be determined by fairly direct means.
By certain urinary examinations it is possible to
know what the kidney is actually eliminating ;
through certain blood examinations it is possible
to determine what the renal glands are failing
to do.
In structure, the kidney is very complex. His-
tologically, the cells are highly differentiated. It
will be recalled that there are two anatomical ele-
ments which go to make up one functioning se-
cretory unit : the glomerulus and the convoluted
tubule. The former is a small tuft of capillaries
so tortuously coiled and wound upon themselves
that the blood in passing through them, is ex-
posed to a large filtration surface. Wdiat passes
through this filtration bed — the filtrate — is col-
lected by means of a capsule surrounding the
glomerulus and is conducted on through the con-
voluted tubule. The latter forms the second ele-
ment of the secretory unit.
Physiologists are not all agreed on the exact
nature of the cellular activity which takes place
respectively in the glomeruli and tubules, partic-
ufarly in regard to osmosis, selective secretion
and selective absorption. Yet for the present it
will suffice to say that by a combination of these
processes, certain waste products are eliminated
from the circulating blood. It is held that water
and salts are filtered out of the blood in its pass-
age through the glomerulus. Beyond all question
it is known that certain of the renal cells, partic-
ularly those of the loop of Henle, possess the
power of selective excretion. It is also known
that many substances which are eliminated by the
•Read before the Iowa and Illinois Central District Medical
Society, Davenport, Iowa, August 25, 1921.
VoL. XII, No. 10]
Journal of Iowa State Medical Society
411
kidney must be present in the blood in certain
definite concentration before their excretion be-
gins. For example, glucose is present in the blood
normally in a concentration of from 8/100 to
12/100 of one per cent or an average of one gram
per liter. Normal kidney cells do not eliminate
it. If this amount of sugar were to double or
treble then the elimination would begin and a
glucosuria be the result. The same principle
holds for the elimination of many products of
intermediary metabolism. In fact, all chemical
elements of the blood, such as urea, uric acid,
creatinin, ammonia, lipoids, amino-acids, sodium,
potassium, iron, carbonates, sulphates, chlorides,
etc., are maintained at a remarkably constant and
fixed level of concentration due to the selective
mechanism of the renal epithelial cells.
Ordinarily, we conceive the primary function
of the kidney to be that of urinary excretion, but
of equal if not greater import, is the additional
duty of maintaining the proper equilibria in the
blood. And from the point of view of what hap-
pens in the nephritic individual, this latter func-
tion is of the utmost importance.
From the foregoing, some idea may be had of
the normal function of the kidney. When it is
realized that this process must go on whether we
are awake or asleep, active or inactive, or on an
acid or alkaline diet, under the most extreme va-
riations in environment, and in the presence of
disease affecting other parts of the body, it will
be seen that the efficency of the normal kidney
is nothing short of marvelous.
This leads us to the consideration for a moment
of what factors may impair kidney function. I
have recently read an article on chronic nephritis
by Prof. Ringer.^ His views regarding the
etiology seem to me so unique and yet so sensible
that I shall take the liberty to quote from his
article. He says :
It is in the nature of human inquisitiveness to look
for a cause for every disturbance in the normal run
of events. It is also natural for us to find something
to blame it on. In regard to chronic nephritis, if we
find the patient gives a history of scarlet fever, ton-
sillitis, malaria, pregnancy, exposure to cold, etc.,
we feel satisfied to put some blame on them. Since
there are very few people who have not had one or
more of the above diseases, and since it is definitely
known that scarlet fever, tonsillitis, malaria, etc.,
may be followed by acute nephritis, and since acute
nephritis frequently is followed by chronic nephritis,
the chain of evidence seems fairly well established
that these infectious diseases are largely the causa-
tive agents of chronic nephritic involvement. In
1. Ringer, A. L. : American Journal Medical Sciences, June,
1921, V’ol. clxi. No. 6.
some cases in which we get a history of absolute
well-being throughout the entire period of the pa-
tient’s life, without any history of illness whatso-
ever, we put the blame on some “noxious poison’’
or some “product of metabolism’’ and let the matter
go at that.
To my mind this does not at all seem a satisfactory
explanation of the cause of nephritis. When we ad-
minister small doses of uranium nitrate to animals,
a severe form of nephritis is set up. It does not at-
tack some and leave out others, but attacks every
animal. The same is true for every nephrotoxic sub-
stance, be it cantharidin, lead, mercury, tartaric acid,
oxalic acid, etc. They all attack the kidneys of
every animal that receives the poison. When we see
a large number of human individuals develop scarlet
fever, some of most severe type, and come out with
kidneys unaffected, whereas in others the mildest
attack will be followed by nephritis, the same being
true for tonsillitis, malaria, pregnancy, exposure to
cold, etc., I cannot but feel that these intoxications
play but a secondary role, i.e., merely an exciting
role and that the primary seat of trouble lies in the
kidney itself. We can readily conceive of organs in
the human body at birth being of functional capacity
below par. A great many combinations may go
wrong during the period of embryonic development,
especially during the period of differentiation, giving
rise to single organs which may not be equal to the
task thrown upon them in later life and which will
break under the strain, giving rise to abnormal phy-
siologic function, disease and finally pathology.
My conclusion, therefore, in regard to the causes
of nephritis is, that all the factors usually mentioned,
as the etiologic factors, as infection, exposure, preg-
nancy, autointoxication, etc., are the precipitating
causes, but underlying that the patient’s predisposi-
tion plays the greater role.
If the individual goes on in life without any se-
rious infection or intoxication he may stay well. As
he progresses in life the weak organ is the first one
to show signs of “old age’’ and begins to fall behind
in its function.
Regarding the pathological physiology of the
kidney on a basis of the foregoing general con-
siderations, we may readily see that any disturb-
ance in the glomerular function will be followed
by disturbance in the water and salt elimination.
Clinically, this may result in an accumulation of
water in the tissues, with oedema and general an-
asarca, depending on the severity of the case. If
salts are imperfectly eliminated they will increase
first in the blood and then the tissues, and water
will be held back to keep these in isotonic solu-
tion. A kidney like this may have no trouble in
disposing of the products of protein metabolism,
like urea, uric acid, and creatinin. Such a patient
may be said to have a salt retention nephrosis,
and that such a condition actually does occur is
412
Journal of Iowa State Medical Society
[October, 1922
evidenced by the fact that simply a salt free diet
will be the means of ridding a patient of oedema
when all other means fail.
On the other hand disturbances in the tubular
portion of the kidney will cause an interference
in the elimination of the non-protein nitrogens,
while water and salts maA* be secreted perfectly.
A chemical examination of the blood in the more
advanced cases will yield an abnormally high
amount of urea, uric acid, or creatinin or all of
them, and simultaneously in the urine a corre-
sponding diminution of these substances together
with a specific gravity which is persistentlv low
and fixed, i. e., not showing the usual hourly
variations in relation to meals and sleep.
Clinicall}-, these patients may present a greac
variety of symptoms. Frequently their first warn-
ing is through the refusal of life insurance. They
may have no subjective symptoms. Again, there
ma}- be nothing more than simply a tired feeling,
especially in the afternoons. The blood pressure,
if taken, will be found to range from 150 to 180.
As these cases progress, other symptoms are com-
plained of, such as ; headache, dizziness, shortness
of breath and palpitation of the heart, insomnia,
tinitis aurium, cardio-vesicular and gastric dis-
turbances. Every physician of experience is fa-
miliar with the story of the chronic nephritic and
with the final picture, in the severe cases — retin-
itis, diplopia, irrationality, convulsions, and coma.
Some attempt has been made to classify these
cases on a basis of clinical symptoms. In actual
practice, I doubt the value of such a classification,
but for convenience of discussion one might rec-
ognize three or four groups of clinical symptoms
corresponding to the severity of kidney tubule in-
volvment. (Ringer.)
Group I. In which the patient has no subjec-
tive symptoms, and onR slight objective si.gns,
e. g., a slight rise in blood-pressure.
Group II. In which the patient’s symptoms
are slight, not enough to be incapacitating, but ob-
jective signs more marked and permanent.
Group III. In which the patient is obliged to
limit his daily activities, and the interdependence
of organs, the one upon the other, is seriously
disturbed.
Group I\ . Comprising the patients who show
unmistakable signs of general physical break-
down, decompensation, cardiovascular and ner-
vous symptoms, and whose days are numbered.
Reference to these groupings will be made later
in correlating the results of functional tests with
symptoms.
From a standpoint of kidney structure, then,
there are these two general nephritic syndromes ;
the one arising from interference with the func-
tion of the glomeruli and characterized clinically
by oedema ; the other arising from disturbances
primarily in the tubules, interfering with elimin-
ation of the products of metabolism. In their
later stages both structures may break down and
we see a combination of the two symptoms to
form a third symptom complex, characterized by
both a general water-logging of the body and
metabolic toxsemia.
Since there are many more cases of the second
type than of the first it follows that the tubular
portion of the kidney structure is more vulnerable
than the glomerular, or else the. latter possess i
greater inherent factor of safety.
The diagnosis of nephritis is usually made b)'
the finding of albumin or casts or both in the
urine. Ordinarily the amount of albumin or the
number and character of the urinan,' casts is
taken as an index of the severity of the process.
In a fair percentage of cases of acute nephritis,
this correlation of laboratory and clinical findings
will hold good, although everj- one has had the
experience of finding a heavy albuminuria in a
patient manifesting only the mildest symptoms of
nephritis. On the other hand such a correlation
between the urinary findings and clinical symp-
toms is notoriously uncertain in cases of chronic
nephritis. The trace of albumin and the few
hyalin casts are not criteria of the severity of
chronic kidney disease. If the tests of renal
function have taught us anything, they have
taught us the fallacy of this belief.
The questions arise now, what other means
have we at our disposal for demonstrating renal
impairment? Is it possible to get an idea of
which element of the secretory unit of the kidney
is involved ? Is it possible to find out in a specific
way what the kidney is failing to do, to the end
that treatment might be directed in a more logical
manner ?
Functional Tests
There are four types of functional tests that
we employ today, each of which has its special
advantages.
(I) The first type consists of finding the tol-
erance of the body to certain substances, chiefly
lactose or glucose. Normally, an adult should be
able to take 150 grams of glucose on an empty
stomach without a glycosuria following. This
test is used more in studying carbohydrate meta-
bolism as a whole, than simply the renal phase of
it, although the test is of value in the diagnosis of
renal diabetes.
(IT) The second type depends on the ability
of the renal cells to pick out from the blood and
VoL. XII, No. 10]
Journal of Iowa State Medical Society
413
excrete an inert dye. The best example of this,
is the “Red test” — the dye is phenol-sulphone-
phthalein. It is reliable, efficient, and easily car-
ried out.
The technique is as follows : (a) direct the pa-
tient to drink about a pint of water to insure free
diuresis, (b) Inject one c.c. of phenol-sulphone-
phthalein solution (which contains 0.006 grams
of the drug) intramuscularly, (c) Note the time
and then direct the patient to empty the bladder,
discard the specimen. (iMake due consideration
for enlarged prostates in men and prolapsed uteri
and cystoceles in women.) (d) At the end of
one hour and ten minutes direct the patient to
void. Collect and save the specimen, (c) One
hour after the first voiding collect and save the
second hour’s output, (d) Alkalinize with 5 c.c.
of strong KOH solution and dilute both samples
up to 1000 c.c. (g) ]\Iatch the color of each
specimen with a standard.
A normal kidney will excrete not less than 30
per cent or 35 per cent of the dye in the first hour
and about 20 per cent to 25 per cent during the
second or a total of 55 per cent to 60 per cent.
(Ill) The third test is made by a qualitative
study of the urinar)- output. It is based on
the following consideration first suggested by
Schlayer and Hedinger and developed in detail by
Mosenthal.
If we collect the urine of any normal indi-
vidual for a twenty-four hour period in two
twelve hour portions, starting the first twelve
hour period at 8 ;00 a. m., and the second twelve
hour period from 8 p. m. to 8 a. m. the following
day, we find that the relationship of day excre-
tion to night excretion is constant both in quan-
tity and quality, provided the individual has had
his principal meal in the daytime, supper at 5 :00
p. m., and does not eat or drink till the next
morning.
The nocturnal output will be under -KX) c.c.
The relation of day excretion to night excretion
for nitrogen, roughly 3 to 2, and for chlorides,
3 to 1 or 4 to 1.
The reason for this is the following; the food
is injested during the twelve hours of the day.
As quickN as it is digested the products of meta-
bolism like urea, uric acid, the chlorides, etc.,
enter the blood stream. As their concentration
in the blood rises the kidneys excrete them in the
urine. Normal kidneys respond so promptly that
comparatively little is left for night excretion.
Therefore we have a low nocturnal output of
water and less solids.
If, however, the kidneys do not respond so
promptly, and begin to fall behind in their work.
some of the material which should be eliminated
during the day will be held over to the night, and
the proportion of day to night solids will approach
each other. There will be a nocturnal f)olyuria
because, with the excretion of more solids, there
will be a larger amount of water.
By morning all the nitrogenous products from
the blood are excreted and if we examine the
blood then by chemical means it will be found
normal in its nitrogen concentration.
Therefore, it is possible by observing the shift-
ing of the day to the night ratios in salt and ni-
trogen excretion to detect an approaching renal
insufficiency before the blood figures change.
To carry out this test as outlined above requires
more laboratory apparatus and experience than
the general practitioner has. Mosenthal and his
co-workers have shown the close relation existing
between the nitrogen and salt content of the urine
and its specific gravity. They have proposed, in
cases of chronic nephritis, a two hourly test of
the urine during the day and a single nocturnal
specimen. This test is so simple that it may be
carried out while a patient is ambulatory, and
with but little inconvenience. The directions are
as follows : The patient eats and drinks what he
is accustomed to, but must be sure that neither
food nor drink is taken between meals or after
supper. The bladder is to be emptied at 8 :00
a. m., and that specimen discarded. After that
the urine is voided at two hourly intervals until
8 :00 p. m. The next morning at 8 :00 a. m. the
last specimen is voided. The gravity of each sep-
arate specimen is taken and recorded.
In checking over the figures for a normal in-
dividual, it will be found that the maximal gravity
reading is 1020 or over. This signifies that the
kidney is able to concentrate. A high specific
gravity, if the amount of urine is high, amounts
to a guarantee of normal renal function. Another
characteristic of the normal test is the variation
in gravity readings. Mosenthal says that there
must be at least nine points difference between
the maximum and minimum for the twenty-four
hour period. Usually there is a variation of
from 12 to 15 points on the urinometer readings.
A variation of only three or four points is re-
garded as a fixation of the gravity, inability to
concentrate if the reading be low, and impairment
of function is the interpretation. A fixation of
the gravity at a high level occurs in acute and
subacute nephritis, but here the quantity of urine
will also be greatly diminished as will also the salt
content.
(IV) The fourth test for kidney function
consists of examining the blood for products of
414
Journal of Iowa State Medical Society
[October, 1922
metabolism, which are normally found in very
small quantities, and which are found to be
greatly increased in the more advanced cases of
renal disease. As a class, these substances are
known as the incoagulable or non-protein nitro-
gens, chiefly urea, uric acid, and creatinin.
Whenever the kidney falls so far behind in its
work that it cannot eliminate in twenty-four hours
the entire excess of these nitrogenous products in
the blood, then they begin to accumulate. The
blood of a normal individual in the morning be-
fore breakfast contains not more than 20 mg. of
urea, 3 mg. of uric acid, and 2 mg. of creatinin
per 100 c.c. of blood. The blood of a nephritic
who is out of nitrogen equilibrium due to failure
of excretion may contain from 50 to 150 mg. of
urea, 3 to 10 mg. of uric acid, and up to 5 mg. of
creatinin. When a creatinin concentration of 5
mg. is found the case is hopeless, and death from
uremia is imminent.
I should like to say here that these blood tests
have been worked out carefully and in the light of
my own limited experience, seem to be very use-
ful. Those who have had the most experience
are very enthusiastic as to their value.
To illustrate the practical use of the blood test,
let us suppose that a patient consults you on ac-
count of the following train of symptoms; a dull
headache, tires easily, is dizzy at times, and has
transitory visual disturbances. You find his
blood-pressure elevated and a trace of albumin
and a few casts in his urine. You may carry the
examination a step further and find his “Red
test” for two hours to be 35, somewhat under
normal. Your advice to him and treatment will
be much more intelligent, if you know whether
he has begun to store up urea, etc., and if so, to
what extent. Sometimes the differential diag-
nosis of gout and infective arthritis will come up
and a blood examination will throw some light
on the subject. Other conditions in which these
tests may be helpful are: in the differential diag-
nosis of eclampsia, prostatic obstruction and other
urologic conditions, malignancy, disorders of the
ductless glands, and in the conditions simulating
uremic coma, particularly diabetic coma, and
drug poisoning.
As in the case with most technical investiga-
tions, so it is in renal function tests, they con-
tribute to diagnoses but do not create them.
In conclusion, these various tests have their
places individually and collectively. With the
exception of the blood examination, they have the
merit of being simple and could be carried out in
some form by every practitioner himself. Ry
means of their intelligent application it is possible
to better understand and better advise that great
class of patients who are suffering from renal
disease. When we can say that a patient has a
phthalein output of 35 per cent with a limited ca-
pacity for water and salt excretion, while his ni-
trogen excretion is normal ; or that another pa-
tient has a fairly normal phthalein output, ex-
cretes water and chlorides perfectly, but falls be-
hind in his nitrogen excretion, and shows a reten-
tion of the same in his blood, we have a de-
cidedly clearer and more useful conception of
what is wrong than if we say simple chronic in-
terstitial nephritis.
The former has a note of antemortem hope in
it ; the latter will require a post-mortem examina-
tion to absolutely confirm it.
TRAUMA AS A FACTOR IN THE ETIOLOGY
OF HYDRONEPHROSIS
Dr. Frederick C. Herrick in the Journal of Urology
for January, 1921, discusses the clinical status of
trauma in producing hydronephrosis. Dr. Herrick
finds two groups of cases which may be fairly due
to injury; first, those in which the demonstrable
tumor appears within a few days or weeks after the
injury. Second, those cases in which after a variable
period of disability following an injury go about
their usual activities but begin to notice gradually in-
creasing more or less, marked symptoms of pain, in-
creased frequency of urination, possibly cloudy urine
or occasional hematuria. In cases of the first group,
the history of trauma and succeeding illness; in those
of the second group, the history of trauma is easily
overlooked and may have occurred one or many
years before consultation. These cases present diag-
nostic pitfalls for the unwary clinician.
As a family physician Dr. Charles E. Sawyer may
be eminently satisfactory to the members of the
Harding family. It was the privilege of the president
to choose his own doctor. That he went back to
his home town for this service is not unusual.
Neither so was the conferring of the title and rank
of brigadier general upon his physicial advisor. But
when he put him at the head of the central body of
hospitalization for disabled ex-service men, it was
apparently without regard for the limitations of the
small town medic. As an executive Dr. Sawyer ap-
pears to have flivvered. And his failure inflicts a
hurt where the country is most sensitive, namely in
the care of its war heroes. If this general who never
saw a day’s military service is holding up relief for
shell shocked veterans he should be speedily removed
from the office and permitted to give his entire time
to the president’s health. — Davenport Times.
VoL. XII, No. 10]
Journal of Iowa State Medical Society
415
Journal of tijc
Solna ^tate jnebtcal ^ottetp
D. S. Fairchild, Editor Clinton, Iowa
Publication Committee
D. S. Fairchild Clinton, Iowa
W. L. Bierring Des Moines, Iowa
C. P. Howard Iowa City, Iowa
Trustees
J. W. COKENOWER Des Moines, Iowa
T. E. Powers Clarinda, Iowa
W. B. Small Waterloo, Iowa
SUBSCRIPTION $2.75 PER YEAR
Books for review and society notes, to Dr. D. S.
Fairchild, Clinton. All applications and contracts
for advertising to Dr. T. B. Throckmorton, Des
Moines.
Ofeice of Publication, Des Moines, Iowa
Vol. XII October 15, 1922 No. 10
EMBARGO ON GERMAN DYES AND SYN-
THETIC DRUGS AND CHEMICALS
It is rather surprising to find in the Associa-
tion Journal of July 22, 1922, an editorial argu-
ment in support of an embargo on German dyes,
in the interest of certain millionaires who have
secured control of the manufacture of American
dyes and who would place every industry that
uses dye, under tribute and the additional cost
shifted to the consumer. Of course, the editorial
avoids direct reference to dyes but refers par-
ticularly to German drugs which are important
products from dyes and appeals to the patriotism
of the American physician in a way quite proper
in time of war but quite aside from American
ideals in time of peace. We have adopted cer-
tain peace resolutions and are presumably on
terms of peace with Germany.
The real interests involved are the interests of
a commercial company known as the Chemical
Foundation, with Francis Garvan as president. Il
appears that in 1917 IMr. Garvan was appointed
.\lien Property Custodian and took over certain
German patents which included a considerable
number of synthetic chemicals and drugs which
American chemists had not been able to make.
Now that we are at peace with Germany, Presi-
dent Harding proposes to return to German own-
ers the property seized. It was found that Mr.
Garvan, without authority, has sold these patents
to his own company for the ridiculous sum of
$250,000 which were, in fact, worth many mil-
lions. It is fair to presume ^Ir. Garvan and his
associates had in mind profits of many millions of
dollars. The editorial was presumably prepared
by interested parties and has set forth claims of
a most extraordinary character such as to create
a feeling of admiration for their ingenuity. The
whole matter has been set forth by the daily press
in all our principle cities and President Harding
has directed the Department of Justice to com-
mence criminal proceedings against Mr. Garvan
and the Chemical Foundation.
The real interest is the dye interest which as
ever}' one knows, has tried persistently to induce
Congress to place an embargo that would give a
few individuals an entire monopoly of dyes to the
great disadvantage of the American people. It is
well known that German chemists had devoted
many years of patient investigation to synthetic
preparation of drugs and chemicals which were
of superior quality. The field was open to chem-
ists of all the world but the opportunity was not
accepted for the reason we are now told that Ger-
many was able to obtain cheap labor (pauper
labor we presume), a rather old story but has
sometimes served its purpose in times of tariff
agitation. It is not clear to us that cheap labor
would be serviceable in the manufacture of syn-
thetic drugs. The Journal of the American Medi-
cal Association has on many occasions, warned us
against American synthetics and imitations. We
are strongly of the opinion that American physi-
cians would prefer German synthetic drugs for
the present at least. We do not doubt the skill of
American chemists; they had their opportunity
but did not avail themselves of it, for reasons that
have been kept secret until now. We believe
there were other reasons for it than the one set
forth. The editor by implication, at least, sus-
pects that we are soon to have war with Germany
for, we are warned, that, “never again should we
permit any foreign domination of our thera-
peutics.” We may say in return that we never
should be at the mercy of commercial exploitation
of the Chemical Foundation or any other drug
monopoly but should be permitted to purchase
our drugs in any market that gives us what we
want ; that is our kind of “Americanism.” It
would be quite to the purpose, for the great Med-
ical Journal, to which we look for enlightenment,
to wait until the government criminal prosecution
for fraud is closed and Congress has disposed of
the tariff question on dyes. The embargo has ap-
parently been settled by vote of the Senate which
has given great offence to certain interests. Must
we always be bound down by commercialism and
to special interests as the only test of “American-
ism
416
Journal of Iowa State Medical Society
[October, 1922
Xow comes Clinical Medicine with an inspired
editorial presenting the same line of argument al-
though more frankly commercial in character. If
it is true that Germany can manufacture dyes and
synthetic chemicals and drugs more cheaply and
better than we can, why should we, as practi-
tioners of medicine and as the American people,
generally tax ourselves in the interest of the
Chemical Foundation or any other monopolistic
corporation ? The spirit in which these editorials
are written is not in the spirit of protest against
destructive legislation but in the spirit of com-
mercialism.
The objections we present to the embargo on
German synthetic chemicals and drugs are based
on the interests of the medical profession and the
public we serve. There is, however, another point
of view which was set forth by Mr. Underwood
in a recent Senate discussion, endorsed by news-
paper editorials, that inasmuch as the German
government owes us certain sums for indemnity
claims that we are justified in seizing private
property, namely, German patents held by the
Chemical Foundation for the purpose of liquidat-
ing American claims. It appears Secretary of
State Hughes holds to a different opinion as to
the ethics of the case and directs that a mixed
commission be appointed to investigate and report
on the legal bearing and on the justice of these
disputed claims. Mr. Hughes is the responsible
representative of the government.
We have so much prided ourselves on our high
sense of justice that it is sincerely to be hoped
that we shall not permit ourselves to be so in-
fluenced by selfish notions and bitterness of feel-
ing as to lead us to do even German citizens an
injustice. We have to confess that this is a
branch of the subject upon which we are not qual-
ified to speak and may safely leave it to inter-
national lawyers and diplomats.
The subject becomes more painful as we read
a pamphlet sent to the address, we presume, of
even,' physician in the United States under the
title, “An Open Letter to Warren G. Harding,
President of the United States.” In this letter
it is made apparent that the President has acted
without knowledge of the facts and that the At-
torney General has made no investigation and that
he had given an opinion unfairly and unjustly, or
in other words, the President and the Attorney
General have conspired to deprive the Chemical
Foundation of exceedingly valuable assets ac-
quired while Mr. Garvan was acting as Alien
Property Custodian. The right of l\Ir. Garvan to
sell to the Chemical Foundation alien property
under the direction of Mr. Wilson and Acting
Secretary of State, Frank L. Polk, or whether Mr.
Wilson or Mr. Polk knew that Mr. Garvan was
the principal beneficiary when the instructions
were given are of course legal questions and
should be settled in the courts. Ordinarily when
a trustee sells property held in trust to himself at
his own figures we should look upon the transac-
tion as somewhat shady.
The propaganda part of the pamphlet addressed
to the medical profession is not convincing. The
alleged generous amounts in financing certain
scientific educational work bears the impress of
“good business.” Whatever may be the legal
status of the matter the Courts or Commission
may determine, there are strong objections, how-
ever, to forcing the users of dyes and synthetic
drugs and chemicals to place themselves at the
mercy of a monopolistic corporation under what-
ever guise it may be. The Senate very properly
refused to grant the embargo, and it is to be sin-
cerely hoped that the Senate will maintain the
same attitude in the future. An embargo or a
prohibitive tariff under the plea presented is con-
trary to every principle of [ustice and right to the
medical profession and the public, and it would
be not a little to the discredit of the profession if
we were caught by this extremely plausible and
active propaganda which shows unmistakably the
great commercial value of these patents to cer-
tain great money interests.
BENJAMIN FRANKLIN AS A MEDICAL
CONTRIBUTOR
It appears, according to the Journal of Florida
Medical Association, that in Franklin’s day there
was little or no medical literature in America.
That in 1785 he invented bifocal lenses, a flexible
catheter, and contributed to the treatment of ner-
vous diseases by electricity. He wrote on deaf-
ness, gout, sleep, lead poisoning, heat in the blood,
infection from dead bodies, death rate in infants
and medical education. He wrote a history of the
Pennsylvania Hospital of which he was the prin-
cipal founder (1751). He also wrote a pamphlet
on innoculation in small-pox.
Disregard of the claims of science when there
is no direct money gain does not seem to be con-
fined to any country. Even the far off Philippine
Islands have a grievance as stated in the Journal
of the Philippine Islands Medical Association.
“The government did not consider it excessive to
defray the expenses of one hundred thirty odd
athletes, representing the Philippines in the Olym-
VoL. XII, No. 10]
Journal of Iowa State Medical Society
417
piad that took place in Shanghai last May ; but
our critical financial condition was found to be a
good excuse for suspending the trip of our medi-
cal representatives already appointed to the Inter-
national Congress of Tropical Medicine that was
to be celebrated in Welleoreden, Java, at the be-
ginning of August this year. Five representatives
appointed, expenses 5,000 or 6,000 pesos (dol-
lars).
BRACHIAL BIRTH PARALYSIS
Dr. Albert W. /\dson of the Mayo Clinic in an
address before the Idaho State Medical Society,
published in Northwest Medicine, for February,
1922, presents observations on forty-five birth
paralysis patients. He states, while birth palsy
has been known to occur in normal easy labor, it is
more generally the result of prolonged and diffi-
cult labor. Adson shows that 73 per cent of their
group of birth palsies were forceps deliveries.
The relation of birth palsies to shoulder dislo-
cations are shown, Adson finds that in their forty-
five cases twenty had dislocations. The older the
patient the more frequent the dislocation. Ap-
parently showing that the changes in the tissues
of the joint by injuries to nerves favored dislo-
cation as a secondary result of the paralysis.
The treatment by operation does not appear to
give better results than treatment without opera-
tion. Of the forty-five cases given by Adson,
twenty- five were operated upon, fourteen were
failures, and eleven with 40 per cent improve-
ment. Treatment by operation should not be
entirely disregarded. All treatment should be
based on the cause and degree of injury. Dr.
Adson analyzes all his cases and places a fair
estimate on the value of the treatment employed,
but we cannot avoid the impression that quite as
good results come from non-operative treatment.
It is apparent that Dr. Adson does not agree
with Dr. F. Turner Thomas of Philadelphia as to
the cause of birth paralysis. We are to conclude
that Dr. Adson attibutes the paralysis to injury
to the brachial nerves and the subluxations are
secondary to an injury to the nerves arid to
changes in the tissues due to the paralysis. Dr.
Adson states that only twenty out of forty-five
cases had dislocations. Dr. Thomas contends
that it is not to injury of the nerves that birth
paralysis is due, but to a primary subluxation of
the head of the humerus ; that the true lesion is
a joint lesion and should be treated as such. The
important consideration is an early diagnosis re-
duction and proper retention. If this could be
accomplished these late birth brachial paralysis
would disappear.
Dr. Thomas presents a personal experience of
471 cases in a paper jiublished in the American
Journal of Medical Science for February, 1920,
and in the Transaction of the College of Physi-
cians (Philadelphia) for 1919. This paper pre-
sents an exhaustive resume of the subject and is
worthy of careful study. If Dr. Thomas is cor-
rect in this contention, and his views seem log-
ical, it becomes the duty of the accoucheur to ex-
amine the shoulder of the new born with great
care for evidence of paralysis, deformity or ap-
parent pain on motion, or inability to move the
arm, for evidence of dislocation, or partial dislo-
cation, and if the conditions above described are
found reduce and retain in position for a proper
period of time and then employ active motion.
EVIL EFFECTS OF TOBACCO
At a recent meeting of Rock Island surgeons
at Colorado Springs a paper was read setting
forth the deleterious effects of tobacco on em-
ployes, and incidentally on people in general, in-
cluding we assume, doctors too. It is not specif-
ically stated that any considerable number of rail-
way disasters were due to the effect of tobacco
but from the paper and some of the discussions,
we may easily suppose that was the case. To-
bacco users may be of the opinion that much of
the paper and discussion grew out of personal
prejudice not a little influenced by the fact that
when doctors meet in convention the rights of
non-smokers receive little consideration except
when the meetings are held in churches which are
usually avoided, if possible.
The principle reason we have in referring to
this subject is the editorial by Dr. L. J. Mitchell
in the May number of the Official Journal of the
American Association of Railway Surgeons, (The
Surgical Journal). Dr. Mitchell who knows more
about all sorts of things than anyone we know,
goes over the subject in an exhaustive manner.
We would advise all smokers who have any
doubts about the effects of tobacco to read this
editorial. Dr. Mitchell finds the strongest argu-
ments against the use of tobacco in the report of
a meeting of the deans of women in colleges re-
cently held in Chicago, in which it was held that
smoking is “filthy, vile, dirty, nasty, vulgar.”
This appears to refer to co-eds, if so there should
be no controversy. Dr. Mitchell’s final comment
on this report is, “We read nothing about ambly-
opia, but seeing the good ladies were not physi-
cians, this may be pardoned.”
418
Journal of Iowa State ^Medical Society
[October, 1922
The Boston [Medical and Surgical Journal for
July 20, 1922, presents some interesting foreign
notes abstracted from Science.
At the time of the celebration of the centennial
of Pasteur’s birth, in Strasbourgh, a congress of
hygiene and bacteriolog)- will be held for discus-
sion of questions relating to disease. In order to
s!iow the sympathy of Great Britain with the pro-
jects of the French committee, a British commit-
tee composed of the following members has been
formed: A. Chaston, H. E. Field, Professor
Percy R. Frankland, Sir John [M’Fadyean, Pro-
fessor C. J. Mardin, Sir W. J. Pope, Sir James
\\’alker and Sir Almroth Wright.
On June 4, at the special invitation of the gov-
ernors and the medical school. Professor Harvey
Cushing took over the directorship of the surgi-
cal unit of St. Bartholomew’s Hospital and re-
placed the director, [Mr. Cask, for ten days. The
compliment uas, as it were, a return for a like
compliment paid to [Mr. Cask last year, when he
acted as temporary chief of the Peter Brent
Brigham Hospital, Boston, to which Dr. Harvey
Cushing, as professor of surgery at Harvard, is
surgeon.
Dr. Xorman Fridge of Los Angeles in a paper
published in The American [Medical Press for
June, 1922, under the title of “The Xursing Situ-
ation to Hospitals and Care of the Sick,’’ says in
relation to hospitals.
New Fashions in Hospitals
But there is great need for more hospitals, especially
for those so built and so endowed that the room
charges to patients would be much reduced from
present figures, say to one dollar per day. Hospitals
should be built more cheaply. Inexpensive detached
buildings should be the ideal. I know fireproof struc-
tures are desirable, but they are very costly. And
substantially all of us live through our whole lives in
combustible houses. W hy, then, couldn’t we consent
to go to a cottage hospital that is half as combustible
as our dwellings?
The hospital fashion should be modified. More
patients should be cared for in their own homes, and
man}- more minor surgical operations should be done
there. One of the leading surgeons has just told us
how he elects to operate on certain cases in their
beds in the hospital. It would mean more labor on
the part of the household, more inconvenience for
the doctors and nurses. And the household would
need to be educated in the unusual care required —
and that could be done — and would be for the large
benefit to the community.
CONSULTATION ON VENEREAL DISEASE
BY CORRESPONDENCE
The Division of Venereal Diseases of the United
States Public Health Service, Washington, D. C., has
arranged with several prominent syphilographers and
genitourinary surgeons whereby the advice and coun-
sel of these authorities is to be made available to
general practitioners. The plan is referred to as
“Consultation by Correspondence.”
The method of utilizing this service is for private
practitioners who have under their care any cases of
venereal infection which they wish to describe to a
specialist and ask for advice in regard to treatment
or to the method of procedure in handling the case,
to send to the State Board of Health, B. of V. D. C.
(Bureau of Venereal Disease Control) a letter set-
ting forth all of the data which they wish brought to
the attention of the proper specialists. These letters
will be forwarded to the Public Health Service who
in turn will secure an answer to the communication
from the best known specialist on the particular
phase of the subject discussed in the communication
from the private practitioner. It is believed that this
sort of correspondence between private physicians
and well known specialists will be of material bene-
fit in many cases. This service is, of course, entirely
free of charge.
IOWA STATE UNIVERSITY NEWS NOTES
Dr. Don !M. Griswold, Iowa City
Mr. E. A. Xixon has been appointed assistant in
pharmacology. College of Medicine, S. L'. I. Mr.
Nixon was formerly assistant pharmacist at S. U. I.
Hospital.
Dr. G. H. [Miller of the Nelson [Morris Research
Institute, Chicago, has accepted a position as assist-
ant professor of pharmacology at S. U. I. College of
Medicine.
Dr. Marcus P. Neal, assistant professor of path-
ology and bacteriology at the State University of
Iowa, College of Medicine, Iowa City, has accepted
a position as professor of pathology and bacteriology
at the University of [Missouri School of Medicine,
Columbia, [Missouri.
A meeting to revise the rules and regulations of
the State Board of Health, was held in the medical
building of the State L^niversity, Iowa City, Friday,
August 4. Those present were Dr. Rodney P. Fagen,
secretary-executive officer, and the board members:
Dr. Frank T. Launder, Garner; Dr. H. C. Eschbach,
Albia; H. Pederson, sanitary engineer; Dr. C. S.
Grant, Iowa City. J. J. Hinman, Jr., chief of the
water laboratory. State University, and H. C. Griefe,
assistant secretary, Des Moines, were also present at
this meeting.
Dr. Grant entertained the members of this assem-
VoL. XII, No. 10]
Journal of Iowa State Medical Society
419
bly at a 6:00 o’clock dinner at his home on Summit
street.
Dr. Steindler, professor of orthopedics at the Uni-
versity of Iowa has been spending the summer in
Europe, leaving Iowa City the latter part of May.
He is e.x.pected to return the first part of September.
During his visit in Europe he was particularly in-
terested in visiting the clinic of V. Putti, Bologna,
Italy. He has also visited the various orthopedic
clinics in Vienna and in Germany.
Dr. Robert V. Funsten who has for four years
been connected with the orthopedic service of the
University Hospital at Iowa City as first assistant
and instructor, is leaving in September to take up
the practice of orthopedic surgery in Detroit, Michi-
gan, where he will be connected with orthopedic
work at several institutions, including the Veteran’s
Bureau Hospital.
Miss Marion Bell has taken up her work as bio-
chemist in the department of pediatrics.
Dr. Senska of the class of 1911 has just arrived at
his post as medical missionary in Sakbayeme, West
Africa.
Dr. Charles Thomas of the Student Health De-
partment has been in Baltimore for two weeks.
Miss Helen Stewart, director of the School for
Public Health Nursing attended a meeting of the
three national nursing organizations at Seattle,
Washington. Each three years, the national organ-
ization for public health nursing, the national league
for nursing education and the American Nursing
Association, have a series of joint meetings. This
meeting brings together those persons most inter-
ested in these lines of nursing work.
iliss Jesse L. Chapman, city nurse for Iowa City,
has resigned and Miss Margaret Kemmerer has
been appointed to fill the vacancy.
Mr. Harley Dolan has recently been appointed
technician in the laboratory of the head specialties
clinic.
Miss Josephine Crielman, formerly connected with
the University Hospital, is returning to be the super-
intendent of the Nurses’ Training School.
Dr. A. B. Mulsow is acting as profesor of path-
ology and bacteriology for the present school year.
RADIUM INSURANCE
Dr. George E. Pfahler of Philadelphia, a few
months ago, became very much interested in radium
insurance because an announcement was made that
Lloyd’s of London had raised the annual premium to
5 per cent. Refer to editorial comment in the Jour-
nal of Radiology, Volume 3, No. 4, April, 1922, page
145.
Dr. Pfahler called for assistance of the radium pro-
ducers in order to secure a radium policy that would
give ow’ners protection under all reasonable condi-
tions, and he suggested that a policy obligating the
company to pay 75 per cent, of any loss instead of
100 per cent would doubtless give a more favorable
rate and a coverage that would be acceptable to
doctors.
Working on this suggestion, we are pleased to an-
nounce that the Insurance Company of North Amer-
ica, a strong, old and reliable American insurance
company, is prepared to write policies covering all
risk, but with a loss payment of 75 per cent. This
policy is offered at 2 per cent per year.
In developing this policy, a firm of insurance
brokers in New York rendered very valuable assist-
ance. We, therefore, take the liberty of suggesting
that if you are interested in radium insurance, you
communicate with Mr. O. ^I. Middleton of the firm
of Alberti, Baird & Carleton, Inc., 50 Pine Street,
New York. A request to Alberti, Baird & Carleton,
Inc., will bring you a specimen policy.
We have studied the radium insurance question for
a long time and are glad to bring this policy to your
attention since it has our complete approval. — Boston
Medical and Surgical Journal, June 1, 1922.
DES MOINES AS A MEDICAL CENTER
For the past forty years Des Moines has enjoyed
a reputation as a medical center in the iMiddle West.
In 1882 the first medical school of the city was or-
ganized and occupied rooms in the old Register
building on the corner of Fourth and Court. From
that date until 1913 the city was continuously the
seat of a medical college, and during the last ten or
twelve years the school was a department of Drake
University and ranked very high in the personnel of
its faculty, the character of its instruction, and the
class of its students. The graduates of the Des
Moines Medical Colleges are scattered throughout
almost every state in the union.
Des Moines early recognized the necessity for
adequate housing and nursing of the sick, and the
Mercy and the Iowa Methodist Hospitals were or-
ganized more than twenty years ago to fill this need,
and throughout this period, these institutions have
rendered a conspicuous service to the community
and the medical profession in the facilities they have
afforded for the study and treatment of disease.
During the early part of this period these institutions
developed largely around surgical clinics, but witli
the modern trend for the hospitalization of medical
and obstetrical cases as well, these with the newer
institutions, viz.; the Iowa Lutheran, the Iowa Con-
gregational, and the Citj- Hospitals have developed
420
Journal of Iowa State Medical Society
[October, 1922
special departments which are equal to any in the
largest cities of the land.
These five leading hospitals are all modern in their
construction and appointments and afford a com-
bined capacity for six hundred and twenty-five beds.
Each has its own nurses training school organized
and conducted according to the standards of the
state. They are equipped with the recognized mod-
ern facilities for laboratory and clinical studies, and
for special treatments of a very high order. On
their staffs are well trained representatives of the
leading medical and surgical specialties, as well as
x-ray and laboratory specialties, a number of whom
have been medical teachers. Des Moines maintains
a modern City Hospital of seventy-five beds for the
indigent of the city and the county, and this institu-
tion houses the Alunicipal Health Center where dis-
pensary services are rendered daily to fortj' or fifty
patients. Daniel Glomset, M.D.
Remember the Des Moines Clinic
October 18, 19, 20
SOCIETY PROCEEDINGS
Greene County Medical Society
Greene County Medical Society met Friday, July
28, at the home of Dr. and Mrs. B. C. Hamilton, Sr.,
following attendance at the tubercular clinic. A
picnic supper was enjoyed following which Dr. John
Peck of Des Moines gave a very instructive talk on
Care and Treatment of the Tuberculosis.
The following were present: Drs. Kester, Reed
and wives of Grand Junction; Dr. Shipley of Rippey;
Dr. and Mrs. Waddell of Paton; Drs. Gressler, Spear
and wives of Churdan; Dr. Pressnell of Scranton;
Drs. Hoyt, Hamilton, Jr., Dean, Hamilton, Sr. and
wives of Jefferson; Dr. John Peck of Des Moines.
Jones County Medical Society
Jones County Medical Society met July 17, to
honor Dr. H. W. Sigworth, Sr., father of the Water-
loo physician of the same name. The elder Dr. Sig-
worth, who is now eighty-five years old, has prac-
ticed medicine for fifty years in Anamosa. He pre-
viously practiced for tw'elve years in Waubeek, Linn
county. Present also at the meeting was Dr. F. B.
Sigworth, a son of Dr. H. W. Sigworth, Sr., who is
practicing medicine at Anamosa.
Dr. ,H. W. Sigworth, Jr., read a paper on Conser-
vative Surgery for the Safety of the Patient, and Dr.
J. Lynne Crawford, Cedar Rapids, read a paper on
Duodenal Ulcer. Another speaker was Dr. Charles
Ryan, Des Moines.
Another angle of interest was that Dr. J. Lynne
Crawford is the son of Dr. G. E. Crawford, who
bought out Dr. H. W. Sigworth, Sr.’s practice at
Waubeek when the latter moved to Anamosa a half
century ago.
A dinner was had at the meeting, at which many
interesting reminiscences of the early days were re-
counted.
Van Buren County Medical Society
The Van Buren County Medical Society held its
fourth annual picnic Friday, July 14 at Chautauqua
Park, Farmington. About 100 were present, includ-
ing doctors, their families and friends. Physicians
were there from Ottumwa, Keokuk, Burlington, Me-
diapolis, as well as nearly every doctor in Van Bu-
ren county. Dinner was served cafeteria style about
1 :00 o’clock, after which the following program was
given:
Peptic Ulcer, Dr. L. A. Coffin of Farmington.
Diagnosis of Troubles in Lower Right Quadrant,
Dr. C. R. Armentrout of Keokuk. Infections of the
Hands, Dr. C. H. Magee of Burlington.
The officers are: President, Dr. T. G. AIcClure of
Douds; vice-president. Dr. G. R. Neff of Farmington,
and secretary, C. R. Russell of Keosauqua.
1922 Mid-Summer Session Austin Flint-Cedar Valley
Medical Association
Tuesday, July 11, 9:00 A. M.
The Importance of Early Treatment of Chronic
Nasal Catarrh or Chronic Inflammation of the Nose
Proper, Dr. James K. Guthrie, New Hampton.
Something to Think About, Dr. Frank Wm. Por-
terfield, Waterloo.
The Production of the Artificial Menopause, Dr.
F. H. Cutler, Cedar Falls.
Acute Appendicitis, Dr. W. A. Rohlf, Waverly.
1:00 P., M.
Some Obstetrical Problems Involved in Still
Births and Deaths of New Born Infants, Dr. Charles
S. Bacon, Chicago, Illinois.
Treatment of Placenta Previa, Dr. George A.
Plummer, Cresco.
Pulmonary Abscess, Dr. W. W. Bowen, Fort
Dodge.
Recent Progress in the Treatment of Chronic Em-
pyema, Dr. Carl A. Hedblom, Rochester, IMinnesota.
Some Factors to be Considered in the Etiology of
Backache, Dr. H. W. Aleyerding, Rochester, Minne-
sota.
Early and Late Lesions, Due to Electric Injuries,
Dr. Oliver J. Fay, Des Moines.
Prof. Miloslovich of the Marquette Medical School
of Milwaukee, Wisconsin, did not appear on the
printed program, but the association was fortunate
in securing his consent to address the gathering here.
A banquet was given at 6:30 p. m. Tuesday at the
Firemen’s Theatre, followed by a dance.
Wednesday, July 12, 8:00 A. M.
The Function of the Gall Bladder, Dr. G. M. Crabb,
Mason City.
Intestinal Obstruction, Dr. Monroe M. Ghent, St.
Paul, Minnesota.
The Doctor and the Neuropath, Dr. Charles R.
Ball, St. Paul, Minnesota.
A Clinic on Diseases of the Nervous System, Dr.
Clarence Van Epps of Iowa City.
President’s Address, Dr. W. T. Peters, Burt.
VoL. XII, No. 10]
Journal of Iowa State Medical Society
421
1:00 P. M.
Opportunities and Alcans of Giving I’atients Con-
sulting the Surgeon a Better Service — with Special
Reference to the Neuroses, Dr. Henry J. \'anderberg,
Grand Rapids, Michigan.
Mistakes Alade in tlie Treatment of Fractures, Dr.
H. L. Beye, Iowa City.
Ethics in Fractures, Dr. Felix A. Hennessy, Calmar.
Hypertension, with Special Emphasis on Treat-
ment, Dr. J. H. Powers, Saginaw, Michigan.
The Treatment of Bright’s Disease, Dr. Daniel J.
Glomset, Des Moines.
The officers of this association are \X. T. Peters,
Burt, president; E. L. Rohlf, Waterloo, vice-presi-
dent; J. G. Evans, New Hartford, treasurer; L. A.
West, Waverly, secretary.
The board of censors: Dr. L. C. Kern, Waverly;
Dr. O. M. Landon, New Hampton; Dr. A. B. Phillips,
Clear Lake.
Austin Flint-Cedar Valley Medical Association
Austin Flint-Cedar Valley Medical Association will
hold its November meeting at Mason City.
Officers of the association elected at Hampton are:
Dr. E. L. Rohlf, Waterloo, President; Dr. J. G. Evan*;,
New Hartford, vice-president; Dr. L. A. West, Wav-
erly, secretary; Dr. W. E. Long, Mason City, treas-
urer.
Medical Society of Cedar Falls
The City Medical Society of Cedar Falls held a
special meeting Tuesday evening, June 20, at the
Black Hawk Hotel. Dinner was served and the
regular business of the society dispatched. Dr. Brad-
ford of Janesville gave a very interesting talk on the
History of Medicine. His medical career already
filling sixty-nine years is closely associated with the
development of this part of the country. His first
calls were made on horseback, over roads that would
be considered impassable now. His talk rekindled
respect for the high ideals of the profession.
A definite plan was decided upon for the holding
of a series of programs during the ensuing year for
advanced study of medical subjects.
HOSPITAL NOTES
Sister Mary Frances, a Sister of Mercy at St.
Joseph’s Hospital for twenty-seven years, died sud-
denly July 8 at the hospital after an illness of only
six hours. Death was due to a sudden attack of
apoplexy.
The sister was on duty in the hospital during the
morning hours and had just gone into retreat with
other sisters of the hospital when she suddenly col-
lapsed. She was dead before medical aid could reach
her.
The sister joined the order of the Sisters of Mercy
at Davenport, and has resided in Sioux City since
then, excepting two and one-half years spent in the
mother home at Davenport. Sister Mary Frances
had been night superintendent of St. Joseph’s Hos-
pital for the last eight years.
Before becoming a sister, she was Miss Mary Mul-
crome. .She is survived by two sisters. Sister Mary
Bernedinc and Sister Mary Gabriel, both of Daven-
port. She was forty-nine years old.
The doctors of Shenandoah are the first to come
to the assistance of the Hand Hospital in the present
drive for funds. The medical men have voted to give
$500 towards the upkeep of the institution.
Dr. Bert Bahr of Grand Island, committeeman for
Iowa, Nebraska, Kansas and Missouri district of the
National Disabled American Veterans of the World
War was in Des Moines July 30.
Dr. Bahr’s mission includes an inspection of the
disabled veterans hospital at Knoxville. This hos-
pital, according to Dr. Bahr, is wrongly located. In-
adequate train service and the expense of equipping
and building there are the main features of the ob-
jection.
Dr. Bahr maintains that the hospital should be lo-
cated at Iowa City.
Dr. Gladys L. Carr, one of the most eminent prac-
titioners in the science of x-ray, has been secured to
fill the laboratory post at Finley Hospital, Dubuque.
She is a graduate of Tufts Medical College, Boston,
of the class of ’06, following which she was an in-
terne at the New England Hospital for Women and
Children for one year. From 1909 to 1914 Doctor
Carr engaged in private practice in Boston, then go-
ing to the Peter Brent Brigham Hospital in that city,
where she remained until 1918. She resigned this po-
sition to accept a post as roentgenologist with the
American Commission of Relief in the Near East,
seeing active service in Asia Minor. Returning to-
America in 1920, Doctor Carr became roentgenologist
at Burnett Sanitarium, Fresno, California. She is
the author of several works on the x-ray, and a mem-
ber of the American X-Ray Society and the Radio-
logical Society of North America.
PERSONAL MENTION
Dr. and Mrs. F. J. McAllister of Hawarden and
daughter, Morine, who have been spending most of
the past year at Los Angeles, California, arrived
home June 30. The Doctor is much improved in
health.
Dr. John W. Shuman, who has practiced medicine
in Sioux City for ten years, with the exception of
eighteen months in service overseas, has accepted a
place as professor of internal medicine at the Ameri-
can University of Beirut, Assyria. This university,
which was established in 1863 as the Syrian Protest-
ant College, has been doing wonderful work. It
now is non-sectarian and receives students from
many different nations and creeds. Dr. Shuman will
422
Journal of Iowa State Medical Society
[October, 1922
succeed the famous Dr. Harry Graham, who died
after thirty-three years of service at the university.
Dr. Shuman, accompanied by Mrs. Shuman and their
children, will leave this country the latter part of
August. They will remain at Beirut for three years.
If at that time conditions warrant it, they will con-
tinue to make their home there. Dr. Shuman, who
pioneered in the field of internal medicine in Sioux
City, is inspired to take up the work in the East by
the wide field and possibilities for service. Not far
from Beirut, Rev. and Mrs. Desmond Smith are serv-
ing as missionaries on the Presbyterian board. Mrs.
Smith is a sister of Dr. Shuman. He is a graduate of
Geneva College and of the College of Medicine of the
University of Pittsburgh. He is also a fellow of the
American College of Physicians. During his ten
years’ practice in Sioux City he has established an
enviable reputation among the surgeons and physi-
cians. For several years he has been on the board of
trustees of the Trinity Lutheran church. He has also
been active in athletic and club circles.
Dr. C. S. Chase, 331 South Johnson street, Iowa
City, relinquished his position with the College of
Medicine of the University after serving as a pro-
fessor for the past thirty years. During the time he
has been on the college faculty the first fifteen years
were spent as a part time instructor. Dr. Chase has
been professor of material medica, therapeutics and
pharmacology. While Dr. Chase steps out of his
position with the College of Medicine he will not
become wholly separated from the University. He
has been asked to accept a position of state-wide ser-
vice for the medical college, making trips to various
parts of the state recruiting students for the nurses
training school and other similar work. Dr. Chase
also retains his relations with the dental college and
school of pharmacy. Although his new duties will
take him out of the city at times, he will continue to
make Iowa City his home. Dr. O. H. Plant, on the
faculty of the College of Medicine the past two
years, who has had charge of administration of the
department, succeeds Dr. Chase as professor of ma-
teria medica. Dr. Plant came to Iowa City from the
University of Pennsylvania, School of Medicine.
During the two years he has been here. Dr. Plant has
devoted part of his time in the compilation of the
history of the College of Medicine from 1870 to 1920.
The book, which will contain about 600 pages, gener-
ously illustrated, will trace the growth of the college
in an evolutionary manner. The work is nearing
completion and will probably be published late this
year.
Dr. Ben Hamilton of Jefferson has recently re-
turned from Boston, Massachusetts, where he at-
tended courses in pediatrics and physical diagnosis
at Harvard Medical School during May and June.
A tuberculosis clinic was held at Jefferson Friday,
July 28, under the auspices of the Greene County
Medical Society with Dr. John Peck in charge and
County Nurse Green assisting. The medical society
enjoyed a picnic and baseball game following the
clinic.
Dr. C. Corbin Yancey, formerly of Chicago, has
taken over the practice of Dr. John W. Shuman, suite
535 Frances building, Sioux City. Dr. Shuman sails
September 13 for Beirut, Syria, where he will occupy
the chair of internal medicine at the American Med-
ical College. Dr. Yancey intends to engage in the
practice of internal medicine, x-ray diagnosis and
consultation.
Dr. D. H. Nusbaum has opened an office in the
Park building at Storm Lake.
Thirty-one thousand cases have been examined
and treated at the Des Moines Health Center since
its start almost three years ago, a rate of about 1,200
cases a month. Dr. Ruehl H. Sylvester has resigned
to take up private work. Dr. Sylvester will remain
as head of the center until September 1, when his suc-
cessor will be announced.
Dr. Lenna L. Meanes, medical director of the
Women’s Foundation for Health, is now located at
43 East Twenty-second street. New York City. She
expects to be in the East for several months.
Dr. H. I. Wilson has recently come to Ft. Dodge
and is asociated with Dr. G. W. Clark in the First Na-
tional bank building. This is the first step in the or-
ganization of a complete general dental dispensary,
which Dr. Wilson states, is designed as nearly as
possible, after the generous plan followed by the
Mayo Clinic, in general surgery.
Dr. Nelle Noble, 1050 Twenty-fifth street, Des
Moines, entertained a group of the women physicians
of the city at a dinner party August 2 at Harris-
Emery’s tea room.
Dr. A. J. Germain of Chicago has entered into part-
nership with Dr. William Slattery of Dubuque, a well
known physician of that city.
Dr. C. D. Fellows of Algona has been appointed
United States physician and surgeon for that district.
Dr. Newsome of Indianola has entered into part-
nership with Dr. Ernest Slaw of Menlo. Dr. Slaw is
a graduate of the Medical School of Iowa State Uni-
versity and served an internship in the Congrega-
tional Hospital at Des Moines.
Dr. G. W. Rimel has located in Bedford. Dr.
Rimel is a graduate from Iowa University Medical
School.
Dr. E. H. Crane of Odebolt has sold his practice
and hospital in that city and has located in Cedar
Falls where he will confine his practice to eye, ear,
nose and throat diseases.
Dr. E. A. Nash of Bristow purchased the practice
of Dr. E. W. Sproule of Peterson and located there
August 1. Dr. Nash has recently completed a post-
graduate course.
MARRIAGES
Dr. Paul F. Stookey, Kansas City, Missouri, for-
merly of Des Moines and Leon and Miss Clara
Sachse of Kansas City, Missouri, were married June
9, 1922. Dr. Stookey has resigned from the position
of medical officer in charge of the local office of the
United States Veterans’ Bureau, and will leave at an
VoL. XII, No. 10]
Journal of Iowa State Medical Society
423
early date for Vienna, Austria, for six months' study
in the skin clinic.
Dr. Hoyt Stonebrook of Eldora and Miss Norma
Hepburn of Charles City were married at Charles
City, June 5, 1922.
Dr. Thomas J. Irish of Forrest City and Miss
Magdaline Grimm of Iowa City were married at
Iowa City, July 1, 1922.
Dr. W. B. Sperow of Carlisle and Miss Lola Rogers
of Montezuma were married June 20, 1922.
REPORT OF THE COMMITTEE ON AR-
RANGEMENTS, DES MOINES SESSION,
1922
Receipts
Exhibitors $1,200.00
Banquet tickets 412.00
Deficit paid by local physicians’ subscription 598.93
Total $2,210.93
Disbursements
Hotel Ft. Des Moines — banquet and smoker $1,427.00
Address at banquet 100.00
Younker Bros. — ladies’ reception 46.75
Music — banquet and ladies’ reception 50.00
Gail Fitch — orchestra, banquet 24.00
M. Holly — monologue, banquet 15.00
Flowers 20.00
Banquet tickets and seller 9.75
Des Moines Fire Works — caps, banquet 20.00
Badges, janitor and miscellaneous 13.55
Cigars and cigarettes 98.59
G. W. Ball — orchestra, quartette, dancers,
impersonators, soloist, two boxing bouts
(smoker) 160.00
Raymond N. Carr — quartette (smoker) 25.00
Chas. Prerett — magic act (smoker) 35.00
W. B. Lowrey — whistling (smoker) 20.00
Refreshments (smoker) 103.50
Tips (smoker) 30.00
Coolidge Advertising Co. — multigraphing and
mailing 12.79
Total , $2,210.93
Respectfully submitted.
Thos. F. Duhigg,
Chairman Arrangement Committee.
OBITUARY
Dr. E. T. Jaynes, age fifty-three, physician and
surgeon practicing in Waterloo the past thirteen
years, with office and residence at 315 Franklin
street, died recently in Presbyterian Hospital, where
he had been taken for emergency treatment. His
death, wholly unexpected, came before an operation
could be performed and was due to spinal meningitis,
developing from an abscess in the ear.
While Dr. Jaynes had suffered the past month from
the infection of the ear, his condition was not alarm-
ing until yesterday morning. On Monday he at-
tended to his medical duties as usual and was seem-
ingly in good health aside from the ear trouble. Sud-
den stricture yesterday morning resulted in his be-
ing taken to the hospital, where the ailment de-
veloped so rapidly that medical science was power-
less to stay the fatal termination.
Dr. Jaynes had an honorable record for service in
the World War. He enlisted in the medical corps
and was assigned to the Great Lakes training camp
and Fort Sheridan, Illinois, with the rank of captain.
He did valuable service during the influenza epidemic
and also in caring for returned soldiers disabled from
wounds or illness. When discharged he was breveted
major, and returned to his practice and family at
Waterloo.
He was born December 3, 1869 at La Monte, Mis-
souri. Previous to coming to Waterloo he practiced
in Parkersburg and New Hartford. Surviving are
the widow and four children.
Dr. John W. McKone of Lawler died July 16, 1922.
Dr. John W. McKone was born January 26, 1872 at
Lawler, Iowa, the oldest son of Mr. and Airs. James
McKone. He grew to manhood there, was educated
in the Lawler schools and w^as later graduated from
the Aledical School of the Iowa State University of
Iowa City. He also took at post-graduate course in
Rush Aledical College in Chicago. While a student
for his professional degree he spent some months in
New Hampton studying under the late Doctor I. K.
Gardner.
Having completed his training he opened the prac-
tice of his profession in Lawler.
On May 28, 1901, he was married to Aliss Alaria
Burke of New Hampton. To them one child was
born, John Robert AIcKone.
Dr. AI. Hilbert died at Battle Alountain Sanitarium,
South Dakota, January 16, 1922. Alelancthon Hilbert
was born in Harrison county, Ohio, on July 17, 1841,
and at the age of fifteen years came to Iowa and set-
tled at Fairfield, Iowa, where he lived until July,
1863, when he entered the army and served in the
First Arkansas Cavalry. He entered the army as a
hospital steward and was promoted to a lieutenancy
and served as adjutant to the regiment. He was
mustered out of service in 1865 and attended medical
college at Ann Arbor, Alichigan, and practiced med-
icines in Clarke county and in 1869 he graduated from
Rush Aledical College, Chicago, and came to Le
Alars, being the first physician to locate there. Alany
stories are told by the early settlers of Dr. Hilbert’s
devotion to duty and of the many arduous trips he
made by field and in flood mounted on his faithful
gray nag with his saddle bags, to relieve suffering
and introduce the little stranger to the world. The
heat of summer and the blizzards of winter told their
tale on his health and he soon discontinued the prac-
tice of medicine.
424
Journal of Iowa State Medical Socie'py
[October, 1922
Dr. George Albert Spaulding, resident of Avoca
for the past thirtj'’ years and a widely known physi-
cian and surgeon in southwestern Iowa, died August
2, 1922, at the Swedish-Emmanuel Hospital, Omaha.
Death was the indirect result of chronic gall-stones
followed an operation. He was about fifty-five years
of age.
Dr. Spaulding was born in the state of New Hamp-
shire, September 30, 1867, and was the son of John
and Augusta Spaulding. When a lad he left the New
England state with his parents who settled near
Charles City, where he attended school.
Dr. Spaulding studied medicine at the State Uni-
versity, Iowa City, and was a member of the class
of 1888. Following his graduation he began practice
at Quinter, Kansas, where he lived two years.
In 1890 he came to Avoca and opened an office.
In February, 1894, he was united in marriage to
Fannie L. Blake. To this union were born three
daughters, Edna, Ethel and Georgia, all at home.
George Louis Day, youngest son of Elmus and
Susan Kelley Day, was born on a farm near Sweet-
land, Muscatine county, March 23, 1870 and died July
20, 1922, at about 8:10 p. m. His early life was
spent on a farm. Later he entered business college
in Davenport and attended for one year, after which
he entered Highland Park College, Des Moines,
where he spent two years. He then enrolled in the
Medical College at the State University of Iowa from
which institution he graduated in March, 1895. Dur-
ing his medical course he spent his vacations in the
office of Dr. F. H. Little of Muscatine. On April 2,
1895, he married Mary Elizabeth Stanwood of Sweet-
land. The following week they moved to Lone Tree,
where they have since made their home and where
Dr. Day has practiced for the past twenty-seven
years.
Dr. Nancy Fleming, a physician and surgeon in
Des Moines for many years, died at her home, 1181
Fifth street, July 29 after a brief illness.
Dr. Fleming was born in Connersville, Indiana, in
1844, but had lived in Iowa since she was a small
child.
BOOK REVIEWS
PRACTICAL INFANT FEEDING
By Lewis Webb Hill, M.D., Junior Assist-
ant Physician to the Children’s Hospital,
Boston; Assistant in Pediatrics, Harvard
Medical School, Octavo of 483 Pages Illus-
trated. W. B. Saunders Company, 1922.
Cloth $5.00 Net.
The interest in infant feeding has grown rapidly
in the last few years. There are numerous reasons
for this interest, the most important of which no
doubt, is the great value placed on infant life on the
part of physicians, and the general sentiment ex-
pressed by the public in the form of child welfare.
Dr. Hill has undertaken to place before the pro-
fession a practical work on infant feeding in which
he states “without being scientific, without being
tiresome.” The first chapter is devoted to the physi-
ology and pathology of digestion and of nutrition.
Chapter two explains how to interpret infant stools
which he regards as of fundamental importance in
determining questions in relation to food and diges-
tion. Human milk and breast feeding occupy two
chapters. It is stated that if all babies could be
breast fed, deaths would be 60 per cent less; an im-
mense saving of life. An interesting chapter is de-
voted to the development of Modern Artificial Feed-
ing, after which comes a discussion of the multitude
of substitutes, first of which comes cow’s milk and
modification of cow’s milk; much detail is given to
this subject in view of the fact that the thought of
cow’s milk comes first after breast feeding. The dif-
ficulty of cow’s milk in certain cases renders some
other form of infant diet necessary so that certain
special preparations must be considered, which re-
quires much serious thought. To meet the diffi-
culties under this head a considerable amount of
scientific consideration and estimation of a balanced
diet is given to meet the nutritive requirements of
the infant. This is carefully set forth in the chapters
devoted to the subject of considerable interest and
difficulty and receives much consideration.
The management of Diarrheal Diseases both as to
care of diet and medicine treatment, and also of nu-
tritional diseases are fully considered. On reading
this book we find many questions in relation to in-
fant feeding that are full of interest to the family
physician and helpful in determining a course of
feeding and treatment for the infant who is deprived
of the advantages of breast feeding.
ABDOMINAL PAIN
By Professor Norbert Ortner, Chief of the
Second Medical Clinic at the University of
Vienna. Authorized Translation. By Will-
iam A. Brams, M.D., Formerly Lieutenant-
Commander, Medical Corps, U. S. N., and
Dr. Alfred P. Luger, First Assistant, Second
Medical Clinic University of Vienna. Reb-
man Company, 141-145 West 36th St., New
York.
We recognize in abdominal pain one of the most
important symptoms in abdominal disease and injury.
The sudden appearance of abdominal pain always in-
vites our serious attention to possible abdominal con-
ditions. We are not always able to determine the
condition from the pain alone, but it is a danger
symptom which attracts our attention and leads to
investigation as to the cause of the pain.
The author furnishes headings for a consideration
of the significance of the pain. Intense diffuse ab-
dominal pain with shock, as illustrated by perforation
of stomach, bladder, ureter, fallopian tube, uterus,
gall-bladder. Severe, diffuse abdominal pain, with
shock and ileus. Following is a discussion of asso-
VoL. XII, No. 10]
Journal of Iowa State Medical Society
425
dated symptoms and conditions which may lead to a
diagnosis. Mild, diffuse, colicky pains; mild, dif-
fuse, abdominal pain not colicky in nature. The
first as illustrated by mild appendicitis, typhoid fever,
dyspepsia, intestinal parasites, etc.; the second by
tuberculous peritonitis, diffuse carcinomatous peri-
tonitis, etc.
Localized abdominal pain, epigastralgia or stomach
cramps, as gastric ulcer pyloric stenosis, gastroptosis,
arteriosclerosis, pulmonary tuberculosis, epigastric
pains, cholelithiasis, duodenal ulcer and many similar
conditions. While pain is the leading factor there
are numerous associated symptoms that must be
taken into account, and these the author evaluates in
arriving at a conclusion as to the cause of the pain
symptom.
Acute, epigastric pains of short duration which are
not cramp-like in nature, as pancreatic affections,
esophagus. Chronic continuous epigastralgia, liver,
gall-bladder, tabes and general neurosis. Colicky
pains in the region of the gall-bladder and right hy-
perchondrium, as liver colic, stone, cholecystitis, chol-
angitis, thrombosis of mesenteric vein, pancreas, ap-
pendicitis, gall-stone. Diffuse pain, over the right
hypochondrium, hepatilis, intercostal neuralgia.
Colic pains in the ileocecal region; intestinal colic,
kidney colic. Acute pain in the ileocecal region; ex-
trauterine pregnancy, acute pericystitis, tuberculous
ulcer of cecum, tuberculous peritonitis, typhoid fever
and other conditions.
Acute pains in the left iliac region; as perisig-
moiditis, mesenteric artery, peritoneal adhesions.
Lumbar pains; renal colics; hematuria, hydrone-
phrosis, disease of the ureter.
We have thus presented an outline of the contents
of this interesting book which has taken up the im-
portant symptoms, pain, character and location, and
has grouped about this symptom associated symp-
toms, x-ray examinations and other conditions which
may lead to a diagnosis.
THE THYROID GLAND
Clinics of George W. Crile, M.D. and As-
sociates at the Cleveland Clinics. Octavo of
228 Pages with 106 Illustrations. W. B.
Saunders Company, 1922. Cloth $5.00 Net.
Dr. Crile’s work on the thyroid gland is so well
known that it is only necessary to announce that a
book has been prepared setting forth his latest views.
It is rare that a book comes to us of equal artistic
attractiveness; the paper, the print and all the me-
chanical work is of the highest order, including the
illustrations. We are presented first, with the Func-
tion of the Thyroid, by Dr. Crile; then, A Physical
Interpretation of the Role of the Adrenals in Ex-
ophthalmic Goitre, Partial Hyperthroidism, Diseases
and Pathology of the Thyroid Gland, by Allen Gra-
ham. The Relation between Diseases of the Thyroid
Gland and Laryngeal Function, by Justin M. Waugh.
Differential Diagnosis of Diseases of the Thyroid
Gland, by John Phillips. Simple Goitre, Colloid
Goitre, Adenoma of the Thyroid, Exophthalmic Goi-
tre, Changes in the Thyroid Gland and numerous
other conditions.
Adrenalin Sensitization Test for Hyperthyroidism,
by Robert S. Dinsmore. A Serum Test for Exoph-
thalmic Goitre, by Frank D’Houbler. The role
played by the radiologist in the diagnosis of goitre,
including methods of examination with beautiful
radiographic plates. Dr. Chester D. Christie pre-
sents a discussion on Basal Metabolism in E.xoph-
thalmic Goitre based on 826 measurements on 472
patients, 43 per cent showed an increase in meta-
bolism of more than 15 per cent above the normal.
Christie believes that basal metabolism measure-
ments are of the greatest value in the diagnosis of
disease referable to the thyroid gland, especially in
reference to borderline cases where the classical
signs are not sufficient to warrant a definite diag-
nosis. He expresses the opinion that, “Basal meta-
bolism estimates during the course of treatment of
patients with exophthalmic goitre, provides a very
accurate index to the progress of the disease.” This
discussion is extremely interesting and important.
Dr. O. P. Kimball presents a goitre survey under
the head of The Prevention of Simple Goitre in Man,
which is of suggestive value in determining the cause
of the disease. Dr. George W. Crile takes up the
question of Surgery vs. X-ray in the Treatment of
Hyperthyroidism. A survey of 208 articles shows a
great diversity of opinion. Means and Aub of the
Massachusetts General Hospital believe that the re-
sults of x-ray are as good as with surgery. Dr. C. H.
Mayo believes that with x-ray treatment remissions
may occur just as remission occurs without treat-
ment and further states, “Our experience has been
failure or but temporary benefit.” Dr. Crile’s conclu-
sions are that, “surgical treatment of hyperthyroid-
ism combined with physiologic rest yields the most
favorable results.”
The remaining chapters are devoted to Preopera-
tive Management, Operation Room Arrangements,
Anesthesia and Operative Technique, In this volume
may be found discussions of the latest questions in
relation to goitre.
SURGICAL AND MECHANICAL TREATMENT
OF PERIPHERAL NERVES
By Byron Stookey, M.D., Associated in
Neurology, Columbia University; Assistant
Profesor of Neurosurgery, New York Post-
Graduate Medical School and Hospital. With
a Chapter on Nerve Degeneration and Re-
generation by G. Carl Huber, M.D., Pro-
fesor of Anatomy, University of Michigan.
Octavo Volume of 475 Pages with 217 Illus-
trations, 8 in Colors and 20 Charts. W. B.
Saunders Company, 1922. Cloth, $10.00 Net.
This exceedingly important work should find a
place in the library of every surgeon, for the reason
that this is an important and difficult branch of sur-
gery, and the results of neurosurgery are so depend-
426
ent on a proper conception of anatomical and physi-
ological connections and operative technique, that a
close study of the factors involved is essential to
reasonable success.
The first chapter is devoted to the anatomy of the
spinal nerves with illustrations followed by a chap-
ter on nerve degeneration and regeneration including
a historical sketch of the work of different experi-
menters.
In chapter three, under the head of Methods of
Nerve Repair, the author undertakes to establish a
standardization of terms employed to save confusion
in nerve operations, thus to avoid unscientific meth-
ods of nerve connections.
Referring in chapter four to direct nerve-muscle
implantation, it is stated that if the central end of a
motor nerve in implanted into a muscle whose nerve
has been cut, it will form end plates and re-establish
motor function. It is also stated that this method
is of limited application, and applies to only a single
nerve-muscle implantation. The chapter is devoted
to this subject. Another chapter relates to Nerve
Liberation. Chapter seven and eight consider the
Technique of Nerve Suture, and the Indications for
the Operation which are the important practical
chapters of the book. Following is a consideration
of the Mechanical Treatment, necessary to securing
the best results.
After considering the important anatomical, physi-
ological and scientific facts, and the technique of
operation and indications for operation, each import-
ant nerve is considered in all its detail. The method
to be employed, the things to be avoided and the
results reasonably to be expected. As a means of
carrying out the operation treatment, excellent cuts
are prepared which will be of the greatest help to
the operator who may not have all the anatomical
facts at hand. Successful nerve surgery is a difficult
branch and before taking up an operation it would be
of the greatest value to the operator to consult the
methods and technique as laid down in this book.
The chapters have been worked out with great care
and skill based on much study and experience.
SYPHILIS IN ITS RELATION TO PREG-
NANCY AND INFANT DEATH
By Amand Routh; Health & Empire, Vol.
I, No. 4, March, 1922.
It is roughly estimated that from 16 to 20 per
cent of antenatal deaths and early neonatal deaths are
due primarily to syphilis. Taking the lower estimate
of 16 per cent, it would mean that in 1920 the deaths
from syphilis during pregnancy and the first week of
life would have been over 15,000 in England and
Wales.
Dr. Routh recommends the following problems for
consideration :
1. Notification of venereal disease, associated with
continuous treatment until cured.
2. Confidential death certificates, or alternatively
[October, 1922
compulsory life insurance of both partners before
marriage.
3. Registration of stillbirths.
4. More facilities for research as regards ante-
natal deaths, and for examinations of all expelled
products of conception.
TUBERCULOSIS IN INFANCY AND CHILD-
HOOD
Lectures Delivered at the Children’s Hos-
pital, Philadelphia, Under the Auspices of
the Philadelphia Pediatric Society, by J.
Claxton Gittings, M.D., Frank Crozier
Knowles, M.D., and Astley P. C. Ashhurst,
M.D., with 23 Illustrations. J. B. Lippin-
cott Co., 1922, Philadelphia and London.
Price $5.00.
These lectures by distinguished professors in the
University" of Pennsylvania are published in a vol-
ume of 273 pages. The book is divided into ten chap-
ters. The first chapter deals wdth General Consider-
ations, Historical, Death Rate, Types of Bacilli,
Childhood Infection, Age Incidence of Fatal Tu-
berculosis, Tuberculosis Infection, Immunity, and
other considerations of a general character.
Chapter two relates to the general principles of
diagnosis. Chapter three considers Tuberculosis of
the Cervical Nodes. This chapter includes the va-
rious tests generally employ^ed in the diagnosis of
tuberculosis. In closing the chapter, the treatment
of tuberculous glands is set forth. Chapter four
takes up Tuberculosis of the L'pper Respiratory
Tract. We are informed in the first place that
“Tuberculosis of the upper respiratory tract is ex-
ceedingly’ rare in children.” Reaching the lungs par-
ticular stress is placed on the method of examin-
ation and the elements of error are pointed out. We
are also informed that “tuberculous bronchitis is en-
courtered most frequently in infants and y’oung chil-
dren under the age of five,” a fact of great import-
ance in considering bronchial troubles in young chil-
dren.
Chapter five points out in considerable detail, tu-
berculosis of the Bronchial Nodes, Pleura and Heart,
and in chapter six. Tuberculosis of the Skin in Child-
hood, by Dr. Frank Crozier Knowles. Chapter seven.
Tuberculosis of the Abdominal Cavity’ and the Genito
Urinary Tract. The frequency of these involvements,
and the importance of early diagnosis warns us to
study this chapter with much care, if w’e hope to save
our patients.
Chapter eight deals with Tuberculous Bone and
Joint Disease, by Dr. Ashhurst, is of great import-
ance but our familiarity with this subject lessens the
danger of error in diagnosis, but there are many fail-
ures in early’ diagnosis.
Chapter nine considers Miliary and Generalized
Tuberculosis. A most trying form of the disease
which so often leads to a fatal result and demands
(Continued on Advertising Page xvi)
Journal of Iowa State Medical Society
Journal of Iowa State Medical Society
XV
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XVI
Journal of Iowa State Medical Society
BOOK REVIEWS
(Continued from Page 426)
are early diagnosis and decision which mav be
reached by spinal puncture. Chapter ten, Treatment;
the hope from treatment rests essentially on an
early diagnosis. \\ e are familiar with the general
line of treatment after a diagnosis is made, our er-
rors are generally errors of diagnosis. The lectures
are exceedingly interesting, practical and helpful.
NEW AND NON-OFFICIAL REMEDIES
During June the following articles have been ac-
cepted by the Council on Pharmacy and Chemistry
for inclusion in New and Xon-official Remedies:
Borcherdt Malt Extract Co.:
Borcherdt’s Malt Cod Liver Oil and Phosphorus.
Intra Products Co.:
\’en Sterile Solution Procaine 0.5 per cent.
Yen Sterile Solution Procaine 2.0 per cent.
Yen Sterile Solution Procaine 5.0 per cent.
Lederle Antitoxin Laboratories:
Pituitarj- Extract — Lederle (Obstetrical).
Pituitary Extract — Lederle (Surgical).
Parke, Davis and Co.:
Diphtheria Antitoxin piston syringe containers.
Antitetanic Serum piston syringe containers.
Antigonococcic Serum 12 Cc. bulbs.
Antistreptococcic Serum 20 Cc. piston syringe
container.
Antistreptococcic Serum 20 Cc. piston syringe
container.
Anti-Anthrax Serum.
Antimeningococcic Serum.
Diphtheria Toxin — Antitoxin Mixture.
Tuberculin B. F. (Bovine).
Gonococcus Yaccine 1 Cc. bulbs.
Gonococcus Yaccine 1 Cc. syringe.
Gonococcus Yaccine 5 Cc. bulb.
Gonococcus Yaccine 20 Cc. bulb.
Erysipelas and Prodigiosus Toxins (Coley) 1 Cc.
bulb.
Erysipelas and Prodigiosus Toxins (Coley) 15
Cc. bulb.
NEW AND NON-OFFICIAL REMEDIES
During July the following articles have been ac-
cepted by the Council on Pharmacy and Chemistry
for inclusion in Xew and Xon-official Remedies:
The Abbott Laboratories:
Xeocinchophen — Abbott Tablets 5 grains.
Louis Hoos:
Hoos Albumin Milk.
^lallinckrodt Chemical Works:
Benz3'l Benzoate — M. C. W.
The Radium Institute of Davenport
(Incorporated)
DAVENPORT, IOWA
An association of physicians for the pur-
pose of making radium therapy conveniently
available in this territory.
Officers and Directors
W. H. RENDLEMAN, M. D., President,
Davenport, Iowa.
F. J. OTIS, M. D., V^ice-President, Moline,
Illinois.
P. A. WHITE, M. D., Secretary, Davenport,
Iowa.
B. H. SCHMIDT, M. D., Treasurer, Daven-
port, Iowa.
D. B. FREEMAN, M. D., Moline, Illinois. *
S. G. HANDS, M. D., Davenport, Iowa. •
J. W. SEIDS, M. D., Moline, Illinois. {
Directors of Radium Therapy I
P. A. WHITE, M. D., Phone, Dav. 542. j
J. I. MARKER, M. D., Phone, Dav. 840. !
The consultation and recommendation of I
our Directors of Radium Therapy may be {
freely sought in regard to eases for which j
radium is contemplated. |
When patronizing the firms
a(Jvertising in this Journal,
• please mention the Journal.
I
I The A(dvertiser will appre-
I ciate it, the Journal will
•
I appreciate it, and You will
j show your appreciation of
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When writing to advertisers please mention The Journal of Iowa State Medical Society
®f)e Jfoumal of tf)c
Kotoa ^tate J^ebical ^ccetp
VoL. XII Des Moines, Iowa, X^ovember 15, 1922 No. 11
MEDICAL IDEALS*
Evan S. Evans, M.D., Grinnell
The beginnings of our profession are shrouded
in mystery, and mytholog)% fable and folklore.
The earliest knowledge we have of our profes-
sional forebears is indissoluably blended with a
fog of myths, superstitions and folktales, most
often, perhaps, relating to the priestcraft, to the
sorcerers, and to the workers of magic. The
earliest physicians of whom we have at all au-
thentic records, were also priests, oracles and
holy men. In those times the function of the
physicians was quite as often the confounding of
an enemy, the propititiations of some devil or
deity, or the procuring of the consummation of
some enterprise, as the healing of the sick, which
was frequently considered to be but the casting
out of devils. The measures used to combat dis-
ease were usually chosen by reason of some fan-
cied relation between the remedy chosen and the
deity involved, as revealed by observation of the
stars, the entrails of some animal killed according
to specific rites. The augurs, the oracles, the
ascendancy of conjugation of heavenly bodies de-
termined the selection of therapeutic measures.
A little later in the history of the world, cer-
tain men whose names still live, added the habit
of observation to the other attributes of the pro-
fessional healer, and it became the custom to give
close attention to the various manifestations of
disease, and to depend somewhat upon these to
furnish indications for the employment of thera-
peutic measures.
Hippocrates was one of the earliest and cer-
tainly the best known of the men who first
blended reason and circumstance in the care of
the sick. This custom has grown among the
Disciples of Esculapius with equal pace as the
mental power and knowledge of the world has
unfolded.
During the middle ages and down into the cen-
tury the therapeutic armamentarium was fur-
nished by the traditions of the past. Many and
noisome are the concoctions used as medicine
even during the last fifty years, chosen at .some
time in the dim and dusty past because of some
fabled relation or affinity to some god or spirit
or devil ; or used because of some dogmatic dic-
tum laid down ages ago by some venerated phil-
osopher-physician of the hazy past.
In view of the state of the world’s knowledge
of the natural sciences for hundreds of years, it
is difficult to believe that the actual practical
benefit derived from the ministrations of physi-
cians totaled very considerable. Their thera-
peutic measures were purely empirical, usually
not too well governed by obser\-ation of clinical
signs, and, being practically unsupported by more
than vague theories as to the structure and func-
tions of the various organs and the changes
wrought by disease, were all too frequently de-
termined by imaginary indications or by the
exigencies of collateral circumstance. It would
seem reasonable then to suppose that charlatanrv
was rife during those times; and excursions into
the by-paths of history reveal the fact that it was
indeed so. There have always been, and we pray
God there may always be, earnest seekers after
ti'uth in the ranks of the medical profession. Hip-
pocrates, Ambrose Pare, Harvey, John Hunter,
Laennec, and Virchow will always stand as the
shining lights of their times. But the rank and
file the profession, grounded, when grounded
at all, only in the ti'aditions of the guild and with
an abysmal ignorance of the laws of natural
science, were in the light of today, the rankest
charlatans.
But even the charlatans have their public func-
tion. Though usually devoid of skill or knowl-
edge necessary to really cure or prevent disease
or ameliorate suffering, even a charlatan supplies
to his patient a measure of moral support. He
is a leaning post, a mental defence against the
terror of an unkind future. True he may really
avail nothing in the presence of disaster but he
has dulled the sharp edge of anticipation; he has
supplied a moral confidence in an auspicious out-
come; and even though the pestilence that walk-
*.\ddress of Chairman, Section on Medicine.
428
Journal of Iowa State Medical Society
[November, 1922
eth at noonday and the terror that flieth by night
ultimately prevail, the poor victim is partially
anesthetized by the comfortable hope which
springs from his dependence upon his physician —
be he quack or savant.
This then is our heritage from the past. Ma-
terial things aside, the fact that the profession
has fulfilled the function of supplying moral con-
fidence to the afflicted has been the justification
through the ages, of the survival of the craft.
On the material side the additions to the world’s
knowledge made in the last 150 years, have given
to us ways and means to add in a practical way,
to our usefulness. We are able to really cure
many diseases, to absolutely prevent many more,
and to ameliorate the suffering incumbent on
most of them. Our information concerning the
laws of nature, the nature of substances, and the
properties of matter is the foundation for this
ability of which we are so proud. And as a re-
sult we now have a two-fold function in the af-
fairs of mankind. We are now bound not only
to strengthen the patient’s hope and confidence,
but also to utilize to the greatest reasonable extent
the world’s knowledge of nature for the physical
relief of the patient, his cure, and the protection
of his associates from similar calamities.
The practice of medicine is today, as always,
founded upon the personal relation between the
physician and his patient. The patient chooses
his physician on personal grounds. He choose;,
him because he thinks the physician well versed,
skilled, and adept but he thinks these things be-
cause of the personal impression the physician
has made on him or on his friends. The average
person has absolutely no criterion by which to
judge of the physician’s skill. He has no avail-
able knowledge with which to gauge the relative
ability of the practitioners of his vicinity, and
actually his choice is made on grounds of per-
sonal taste that have a remote, if any, bearing
upon the qualifications of the practitioner. Any
attempt to arrive at a conclusion by comparison
of results of treatment is apt to lead to serious
error by reason of the overwhelming preponder-
ance of self-limited disease, by the variations in
virulence of individual infections, by individual
idiosyncrasies, and by reason of anomalous cir-
cumstance of which prevision cannot be had.
Practically any practitioner who can hold the
confidence of his patient fulfills the first specifi-
cation of the duty of the profesion, i. e., that of
furnishing a moral bolster against the mental pain
of uncertainty. However, in order that the sec-
ond specification shall be observed, it is necessary
that the practitioner be well versed and reason-
able skilled in the co-ordination of the facts and
in their utilization to the end that disaster be
prevented and disease abolished, and that he exert
the necessaiA- effort to bring about the desired
result.
This may seem to be very trite and common-
place statement to make but when we pause and
reflect that in the not very remote past the physi-
cian was little more than a speculator in the
phenomena of disease,- whose most important if
not entire function was one of morale, we may
consider it not entirely unjustified.
Of late years since the profession has had a
larger working knowledge of scientific things, the
labor of acquiring an adequate equipment of in-
formation and skill has seemed unsurmountable
to many aspirants for professional standing, and
the cults of osteopathy and chiropractic have
sprung up. The ranks of these cults are filled by
men who are as competent as are we to enter into
the personal relation with their patients. They
are as effective as we in supplying moral confi-
dence to a trembling soul. They are fully as ef-
ficient from a scientific point of view as were
most of our professional ancestors of seventy
years ago, for they labored under the same handi-
cap of inaccurate and inadequate conceptions of
nature and nature’s laws. However, they find,
as do we, the overwhelming incidence of self-
limited disease, and their good results are apt to
add up to as imposing a total as will some of ours.
They, too, har e discovered that the man on the
street has no yard stick by" which to correctly
gauge their value from the practical point of
view, and they- have appropriated and improved
upon most of the classical tricks of stage craft
that have been handed down from the ages for
the insurance of preference of the one phy'sician
over the other. Their existence developed out of
the increasing difficulty- of obtaining a profes-
sional education in medicine and it will be per-
petuated, either in the form of the present cults,
or others similarly- founded, by reason of the fact
that they provide a short cut to professional
standing, and because the average man is a
creature of circumstance.
The traditions of the practice of the past, our
own experiences of the fruitfulness of the per-
sonal relation, and the ever present example of
the prosperous irregular, have combined to bear
many of us away from the goal of our ideals.
We have all read and heard of the fruitless strug-
gles of our professional grandfathers against
cholera, diphtheria, yellow fever, etc., and have
known of the love and reverence with which they-
were held in the minds of their patients. With
VOL.XII, No. 11]
Journal of Iowa State Medical Society
429
what wonderful attributes were they not credited
by their clientelle? And yet we know that they
were ignorant of the essential factors of these
things although they were highly successful prac-
titioners. We all have seen our osteopathic and
chiropractic friends, busy, prosperous, respected
and valued citizens of their communities, rated
highly by their neighbors and by their patients,
credited with skill and acumen which they do not
possess, seemingly attaining all the rewards of a
successful career. We all know somewhere
among our acquaintances of professional brethren
whose following of patients and friends is all out
of proportion to their scientific attainments; who
are either poorly prepared to furnish material aid
to their patients or who are too lazy or too hur-
ried to do so. We have all seen and pondered
these things, and the realization of the effective-
ness of the personal relation has sometimes acted
as a soporific to our consciences to the end that
we have directed our efforts to the cultivation of
the personal side of our profession to the neglect
of the scientific side.
Our profession, any profession, in order to con-
tinue to exist, must justify its existence by the
performance of some necessary function in the
body politic. If our profession is to in its old
sphere and without the fulfillment of the newer
ideal of more practical usefulness, it must com-
pete with the irregular cults who are content with
attaining only the personal relation. If we are
to justify our existence as a separate and distinct
profession we must acquiesce in the new duty
and in the higher standard of rendering actual
material assistance to the afflicted. And we
must do it as nearly unanimously as may be. It
is not enough that here and there shall be one
outstanding figure, a modern John Hunter or
Laennec, but we, the rank and file of the pro-
fession we, too, must all of us be earnest search-
ers after truth. We must be diligent and ac-
curate in our observations, not swayed in our
judgments by our imagination, by our desires or
by our fears. We must be persistent and faithful
in our pursuit of new data, and added knowledge.
We men of the medical profession have a re-
sponsibility that is no light one. Individually we
are frequently grieviously at fault. We are too
often lazy, or hasty. We are sometimes dishon-
est with ourselves. We are careless of the pa-
tient’s real interest in our desire to keep our
hands clean. And these things are unworthy of
us. We have the knowledge and the skill if we
choose to make the necessary effort to use it;
but too many of us are satisfied to allow the per-
sonal element to be the predominant element in
our practice.
The movement which is now under way in the
profession which resulted a short time ago in the
standardization of medical schools, and is now
being directed to the standardization of hospitals,
is of colossal significance. There are those of us
who sniffle and gag at what they choose to call
“dictation” and “interference” with their rights
and prerogatives, but it would seem that the ma-
jority of right thinking men are gladly falling in
line. The medical profession has a double duty —
to assist the morale, and to combat disease, and
the awakening conscience of the profession is
coming to see that any personal interest of any
individual physician which is in conflict with the
complete performance of that duty has no stand-
ing. Every physician has a responsibility to his
patients against which the physician has no con-
travening rights or privileges. The sooner this
idea is universally accepted, the sooner the pro-
fession of medicine will attain its widest useful-
ness, and when that happy day comes those of us
who accentuate unduly the personal relation to,
the neglect of the scientific factor in our practice,
who carp and whine about tyranny, who obstruct
assiduously by their efforts and influence the
progress of the profession, will drop out of the
procession and fall back to the ranks of the os-
teopaths and chiropractors, where they belong.
The means and methods of attaining the most
effective fulfillment of our double duty are ob-
vious. The personal relation is one with which
we are all familiar and needs but passing men-
tion here. On the scientific side let us emphasize
some details that seem to be fundamental as a
basis for our efforts. In the first place I bespeak
a thorough examination of the patient. I appre-
ciate that many times personal considerations
render this inconvenient in cases of apparently
trivial nature. A rectal examination in a case of
acute bronchitis in a youth may well result in no
added information; but in men of “prostatic age”
it may frequently have a bearing on the basic
pathology — distended overflowing bladder — renal
and cardiac insufficiency — passive congestion of
the lung. Let us be careful and thorough in our
examinations.
Let us keep notes on our cases — the fuller the
better. Notes of a case with laboratory records
are invaluable in the future handling of the in-
dividual. It is tedious and bothersome but it pays.
When we take our annual jaunt to the city
clinics, let us pay more attention to what goes on
in the morgue, and the pathology laboratory. If
430
Journal of Iowa State Medical Society
[November, 1922
there is any one phase of medicine in which we
are short it is in our appreciation of patholog}’.
Let us ask for autopsies on those of our pa-
tients who die. The infrequency of autopsies in
rural communities is due largely to the infre-
quency of requests on the part of the doctor. I
understand, of course, that there are a few of us
who would not especially care to do an autopsy
unless they got paid for it— and then not with any
considerable degree of understanding. It is a
bogy among doctors, that people are hostile to
the idea of autopsies. A trial will demonstrate
that this is not true to any overwhelming extent.
In one rural community, about half the request“=
for autopsy have been granted, since the doctors
began to ask for them.
Let us use the laboratory. The laboratory is
not the open sesame to diagnosis but it is a great
corroborator and guide. Systematic laboratory
work in our practice in the simpler phases blood
cytology, chemistry and serology, the simpler bac-
teriologic procedures, complete urinalyses and the
histological examination of tissues greatly assist
the doctor in keeping on the right track in his
diagnoses and in checking up on his treatment.
But we can not make our diagnoses on laboratory
reports alone and we must learn to make the
necessarj’ allowance for inaccurate and unusual
reports. ‘Alix brains with your colors” said
Whistler to the young artist who inquired how
he did it. Mix brains with your laboratory re-
ports.
Let us keep up on our reading. It is entirely
possible to arrange a group of current medical
periodicals which will adequately cover the field
with original articles, and with abstracts. Mark
the titles which interest you and have the office
girl file them in a card index. Don’t destroy the
old magazines. Have them bound, and refer to
them often. Set aside an hour a day to read —
and do it religiously.
It all simmers down to work. Work unceas-
ingly and methodic. Let us improve every op-
portunity to add to our experience by more care-
ful examinations, by more frequent autopsies, by
laboratory work, and by systematic reading. The
rewards as regards our following of patients will
depend, as in the past, upon our personality, but
the rewards of doing our work well, and of our
full duty done will ultimately prove to be far
the richer.
ACUTE PERICHONDRITIS OF LARYNX
WITH REPORT OF CASE*
Fr.ank a. Will, i\I.D., Des ^Moines
Acute perichondritis of the laryngeal cartilages
is a comparatively rare condition generally oc-
curing secondarily to some of the more severe
systemic infections; for example tuberculosis, ty-
phoid, syphilis, malignant disease, pyemia, diph-
theria, typhus, er}'sipelas, pneumonia, small-pox,
actinomycosis and glanders. It may also be of
traumatic origin, the result of blows, stab wounds
or burns in the region of the lar}-nx, or the result
of foreign bodies in the larynx or esophagus. It
is also sometimes seen in elderly bedridden sub-
jects and is said to be the result of pressure by
the vertebrae on the cricoid due to the recumbent
position.
Acute perichondritis is practically always of
bacterial origin the mode of infection being by
way of the blood and lymph streams, preceded of
course by an abrasion of the skin externally or
the mucous membrane internally. This disease
is so frequently secondary to tuberculosis, syph-
ilis, cancer and typhoid that any extensive work
on the subject requires a detailed study of these
diseases.
The pathologA’ does not differ to any extent
from the patholog\* of acute perichondritis in
other parts of the body : It is characterized by
inflammation, swelling, edema and resolution or,
as is more usual, by pus formation. The pus
separates the perichondrium from the cartilage
following the line of least resistance until it may
finally point at some spot more or less remote
from its place of origin.
The cartilage itself may be invaded and eventu-
ally slough resulting in laryngeal deformity or
stenosis. The abscess may point internally and
discharge into the larv’nx or trachea or more
rarely into the pharynx or esophagus. Sometimes
the abscess points externally discharging at some
point in the neck. The arj’tenoid cartilage is the
one most affected probably because it is a favor-
ite site for tuberculous ulceration.
The symptoms of acute perichondritis are gen-
erally ushered in with a feeling of malaise, local-
ized pain in the larynx and a moderate rise of
temperature. The local symptoms are by no
means characteristic and very largely depend on
the extent of the infection and the particular
cartilage involved. As the disease progresses the
swelling and edema increase, the voice becomes
* Presented before the Seventieth Annual Session, Iowa State
Medical Society. Des Moines, May 12, 13, 14, 1920. Section
Ophthalmology, Otology and Rhino-Laryngology.
VOL.XII, No. 11]
Journal of Iowa State Medical Society
431
hoarse and there is a feeling of im]iending suffo-
cation, which gives to the patient’s appearance a
particular look of anxiety. In involvement of the
arytenoids phonation and deglutition are painful.
If the cricoid is affected the swelling may involve
the ary-epiglottic fold, the posterior laryngeal
wall, the external surface of the larynx or the sub-
glottic region. Pain increased by external manip-
ulation, dyspnoea and loss of phonation are the
principal symptoms. When the thyroid cartilage
is involved on its internal surface a swelling be-
neath the anterior commissure is iiable to occur.
If the external surface is affected the pus will,
of course, tend to point outwards resulting in ab-
scess of the neck. The principal symptom is in-
terference with phonation. The voice however is
never entirely lost though it may become very
hoarse.
In spite of the fact that there are very few
diseases of the larynx that give rise to similar
symptoms the diagnosis is often difficult. From
the fact that the onset is sudden and accompanied
by fever we know that we have an acute inflam-
matory process to deal with which brings to mind
two other acute conditions with similar symptoms
namely croupous laryngitis and acute submucous
laryngitis. In croupous laryngitis we generally
have an exudate which of itself is sufficient to
make the differentiation, also the febrile disturb-
ance is much more severe. In submucous laryn-
gitis we get a symmetrical swelling of the mucous
membrane on both sides of the larynx, while in
perichondritis the swelling is usually confined to
one side and is irregular and asymmetrical.
.\nother condition which might be confused
with perichondritis is acute inflammation of the
thyroid gland. I will quote a case reported by A.
Bruggeman in the Deutsche Medicinische Wo-
chenschrift, the abstract of which appeared in the
Journal American Medical Association, July,
1920. “Report of a case of acute laryngeal peri-
chondritis in which edematous swellings appeared
on the outside of the throat simulating the pic-
ture of acute thyroiditis. Sensitiveness to pres-
sure was, however, confined to the larynx, which
rules out thyroiditis. Pressure symptoms elicited
in the thyroid were doubtless due to the fact that
in pressing on the thyroid a certain amount of
pressure is brought to bear on the larynx.”
The diagnosis must be made by exclusion of
the acute febrile diseases together with the laryn-
goscopic picture. In involvement of the cricoid
a distinct irregular swelling is seen beneath the
cords encroaching upon the breathing space and
the movements of the larynx are interfered with
on the affected side. If the arytenoid is involved.
we may be called upon to differentiate this con-
dition from tuberculosis of that region. If tu-
berculous, the lesion is generally bilateral and the
appearance of acute inflammation is not so pro-
nounced. Involvement of the inner surface of
the thyroid cartilage shows a swelling projecting
into the larynx in the vicinity of the ventricular
band hiding the true cord and encroaching to some
extent on the breathing space. Involvement of
the external surface of the thyroid cartilage is
much easier to diagnose, as added to the local
and general symptoms we have the information
which can be gained by inspection and palpation.
The prognosis depends largely on the location,
extent and severity of the infection. If the ab-
scess is small and due to its location, does not
spread to any extent, or if it is of the type that
points externally, the prognosis is good, but if the
destruction of tissue is considerable, going on to
necrosis and exfoliation the prognosis is ex-
tremely grave. The prognosis should always be
guarded, as the affection is apt to be long drawn
out, often resulting in greatly lowered vitality
which makes the patient an easy prey for septic
pneumonia and other infections. In the graver
cases there are permanent changes in the voice,
and many times a troublesome dyspnoea resulting
from a laryngeal stenosis.
Treatment — If seen early, the usual treatment
for a rather severe acute laryngitis is instituted
namely, brisk catharsis, rest in bed, use of voice
prohibited, sometimes local blood letting, etc. If
the dysphagia is marked rectal feeding may be in-
dicated. If cough is troublesome inhalations of
comp. tr. of benzoin. When abscess formation is
seen to be inevitable hot fomentations are indi-
cated with free incision under local anesthesia as
soon as abscess becomes localized. If there is much
edema a spray of cocaine and adrenalin may pre-
vent alarming symptoms. Most writers advise
the use of potassium iodide in this disease whether
it be of luetic origin or not. The necessary instru-
ments for a rapid tracheotomy should always be
close at hand. In looking over a number of case
reports one has the feeling that if the necessity
for tracheotomy could have been anticipated
many lives might have been saved. It is, there-
fore, essential in handling this disease that
tracheotomy be not too long deferred.
In 1905 Jackson of Pittsburg made a study of
360 cases of laryngeal disease occurring during
the course or as a sequela of typhoid. In this
series perichondritis occurred seventeen times. It
is interesting to note here that perichondritis in
typhoid was first called to our attention by Bayle
in 1808.
432
Journal of Iowa State Medical Society
[November, 1922
Mayer gives the following statistics from Hans-
berg’s text book : One hundred and twenty-three
cases were reported between 1888 and 1910. In
thirty-six of these cases tracheotomy was per-
formed with recovery of twenty-two cases; one
improved, twelve died and in one the outcome was
not recorded. Laryngo-fissure was done in ten
cases with complete recovery in five cases, im-
provement in four and death in one. Intubation
was done seven times with two recoveries and
five deaths. Endo-laryngeal incision was made in
three cases with two recoveries and one unre-
ported result. External incision was made in
three cases with three recoveries. Nothing was
done in twenty-nine cases, the result being five
recoveries and twenty-four deaths.
Mayer gives the results of his personal experi-
ence as follows : Eleven cases were observed be-
tween 1913 and 1918. Results of treatment:
Conservative treatment, 2 cases — recovery, 2 cases.
External incision, 2 cases — recovery, 2 cases.
Tracheotomy, 5 cases — recovery, 3 cases; deaths, 2.
Laryngo-fissure, 2 cases — recovery, 2 cases.
The number of cases reported in the foregoing
statistics are not of sufficient number to draw
definite conclusions as to the best mode of treat-
ment. It is clear, however, that most cases sooner
or later come to operation, and that the choice of
procedure depends entirely on the individual case.
Case Report
Female, age sixty-two. Family history negative
Personal history, always in good health until eight
years ago when she had an attack of cerebro-spinal
meningitis which left her paralyzed in right arm and
leg and completely deaf in both ears. The paralysis
has completely disappeared and the deafness has
shown a very slow improvement.
February 14, 1921. First noticed that she was
hoarse and throat felt raw, called family physician
who treated throat.
February 15, 1921. Left for California — on arrival
was coughing a great deal, had chilly sensations and
felt very badly. Few' days later noticed that neck,
especially in region of larynx, was considerably
swollen, and that breathing when lying down was
difficult. There was no improvement under treat-
ment and she decided to return home. First came
under my observation March first, voice husky, in-
cessant cough with expectoration of sticky mucus,
temperature 100, larynx and trachea much thickened
with considerable swelling of surrounding soft tis-
sues. Examination with laryngoscope showed vocal
cords normal and movements unimpeded. Mucous
membrane moderately inflamed, no particular swell-
ing at any point.
March 2. Lungs examined by Dr. Peck, nothing
found except a few bronchial rales.
March 3. Sent to hospital. Treatment — rest in
bed, cold compresses, inhalations comp. tr. benzoin,
codeine and heroin for cough.
Alarch 5, 6, 7, 8. Condition about same, cough im-
proved, swelling slightly less. Wassermann nega-
tive, sputum negative. Blood count, reds 4,500,000,
whites 17,000. Septic temperature never over 101.4.
March 10. Greatly improved, swelling much re-
duced, slight cough, temperature 99.
March 11. All symptoms aggravated. Temper-
ature 101.4. Distinct area of redness over cricoid in
median line and over thyroid on right side.
March 13. Incision decided upon unless improved
in few days.
March 15. Swelling more marked. Apparent fluc-
tuation over cricoid in median line. Incision made
over cricoid down to cartilage, under local anesthesia.
Much infiltration but no pus. Another incision made
over thyroid on right side and drainage tube inserted
connecting two incisions.
March 16, 17, 18, 19. No improvement. Still run-
ning septic temperature.
Alarch 21. Alarked swelling over thyroid on left
side. With fluctuation.
Alarch 23. Incision made over thyroid on left side.
About two tablespoons of pus evacuated.
March 24. Swelling much reduced. Can feel bare
cartilage with probe. Pus pocket runs backward on
left side a!bout one and one-half inch. From this
time on patient steadily improved though there still
remains some thickening around cricoid and thyroid.
BIBLIOGRAPHY:
Bruggeman, .V: Laryngeal Perichondritis Simulating Thy-
roiditis. Deutsche Medizinische Wochenschrift 1920. (Abstract
J. M. A., July, 1920.)
Dawson, G. W. : Two cases of Perichondritis of Larynx. Pro-
ceedings of Royal Society of Medicine. (Laryngological Section,
1921.)
Jackson, Chevalier: The Larynx in Typhoid Fever. Trans-
actions American Laryngological Society, 1905.
Mayer, O. : Zur Behandlung der eitrigen Perichondritis der
Kehlkopfknorpel. Wiener Klimische Wochenschrift, 1919.
Scheidler, F. : Zur Kenntnis der Perichondritis larngea I. D.
Kiel, 1901.
THE THORACOSCOPY AND ITS PRACTI-
CAL IMPORTANCE, ESPECIALLY IN
THE SURGERY OE THE CHEST*
H. C. Jacobaeus, IM.D., Stockholm, Sweden
Since about ten years I have occupied myself
with the endoscopy of the serous cavities, peri-
toneum and pleurae. At first I was only engaged
with the diagnostical advantages which could be
gained by such a method. At a case of ascites,
after tapping and replacing by air. I could then
have performed endoscopie and get a clear and per-
spicuous picture of the abdominal organs. There
was thus no difficulty with regard to the liver to
diagnose liver cirrhosis, malign tumor. Picks dis-
*Read before Tri-State District Medical Association, Milwaukee,
Wisconsin, November 17, 1921.
Voi.. XII, No. Ill
Journal of Iowa State Medical Society
433
ease, liver syphilis, a. s. o. Further at carcinosis
and tuberculosis peritonei I could indicate
changes characteristic for these diseases. After
performing endoscopy, and laparoscopy, to be-
gin with only on patients with ascites I have the
last years to a larger extent also carried out ex-
amination on patients without ascites and thereby
has the sphere of the method considerably wid-
ened. I have further combined laparoscopy with
simultaneous x-ray examination of the abdominal
organs with the air still left in the abdominal
cavity. This latter according to Long, Weber and
others. Both these methods of examination com-
plement each other in a very successful way, spec-
ially with regard to the processes of disease in the
liver and spleen and by formations of adhesions
in the abdominal cavity. It is not yet possible to
judge how great a value in practical respect these
methods may obtain.
Without doubt the predominant interest by
these endoscopies centers round the examination
of the pleural cavities, the so-called thoracoscopy.
With regard to the chest cavity we have, as we
know, nothing corresponding to the test laparot-
omy of the abdominal cavity. Further the thora-
coscopy is so simple a method that it can be per-
formed without inconvenience at every exudative
pleurisy which is subject to a thoracentesis. The
ocular examination of the pleural surfaces is in
most cases relatively complete. In cases of s.c.
idiopatic pleurisy I have also succeeded in most of
them to find distinct tubercular noduli. For the
differential diagnosis between tumors and pleu-
risy of other origin the thoracoscopy is of no
small value. After some practice it is at least pos-
sible with some certainty to differentiate between
tumor metastases and tubercular changes. In
doubtful cases one can by test-excision under
guidance of the thoracoscopy decide the nature of
the pleurisy in the special case. Even solid intra-
thoracical tumors can be observed on thoraco-
scopy and their relations to neighboring organs,
the lung, the thorax wall a.s.o. can much clearer
be determined than by any other method. By this
an evident practical use for an intended operation
is gained as we will see further on. This is the
principal use in the great surgery.
The second, and from practical point of view,
most important field for the use of the thoraco-
scopy are the surgical operations which can be
performed directly under guidance of this method
and which I will now describe. On thoracoscopy
at pneumothorax treatment of lung tuberculosis,
a specially fine picture of existing string or mem-
brane-like adhesions between lung and thorax
wall is obtained. This caused me to try to work
out a method under guidance of the thoracoscopy
to remove such adhesions impeding the treatment.
It is a well known experience at the pneumo-
thorax treatment of lung tuberculosis, that a sin-
gle stringshaped adhesion which attaches the
lung to the thorax wall and thereby prevents a
cavity to collapse can cause the failure of the
whole treatment. A recently published paper by
Gravesen from Prof. Saugmann’s sanatorium
contains the following tables which prove the in-
jurious results from these adhesions.
I. Cases with complete pneumothorax without ad-
hesions. (Three to thirteen years after being dis-
charged.) ,
Able to work 23 = 70.2%
Not able to work from tuberculosis 1 = 2.1%
Died from tuberculosis 11 = 23.4%
Died from other causes 1 = 2.1%
Unknown 1 = 2.1%
Total 37
II. Cases with complete pneumothorax but with
localized, extended adhesions.
Able to work 14 = 33j4%>
Died from tuberculosis 28 = 66%%
Total 42
III. Cases with incomplete pneumothorax with
larger or smaller extended adhesions.
Able to work 5 = 11.1%
Died from tuberculosis 39 = 86.7%
Died from other causes 1 '= 2.2%
Total 45
The injurious influence of the adhesions is
simply demonstrated by these tables, which also
give the impressions of the frequency of these ad-
hesions. I have here no time to enter into the
different methods attempted by others to remove
such adhesions. I can only say that none of them
have any practical importance.
As on thoracoscopy it was rather easy to ob-
serve the above mentioned adhesions, the thought
was near at hand to cauterize such adhesions by
introducing a galvanocauter through another
punction opening under guidance of the thoraco-
scopy. The first attempts were made in 1913, and
since then I have altogether performed fifty-five
such operations, of which I will in a shortened
form relate the fifty. The operation is further
performed in nineteen cases by Saugmann ; of
these his assistant Gravesen has published sixteen.
Twelve cases have been published by Holmboe
and further twenty cases by Skargard a.o., six
by Somme, six by Betrup Hansen, three by
Christoffersen, two by Dahlstedt. At the present
434
Journal of Iowa State Medical Society
[November, 1922
moment certainly far more than 100 operations
have been performed. On the picture I will
demonstrate the detailed technic. I nearly always
introduce the thoracoscope, which is done under
local anaesthetic, on the back side, a little higher
up when the adhesions are at the lung apex and
lower down when they are in the lower part of
the pleural cavity.
But of more importance is the place where to
introduce the galvanocauter. Because in most
cases the adhesions are situated upwards and lat-
erally, I have mostly introduced the galvanocauter
in the anterior axillar line in 17-19. I introduce
still higher up in the axillary line by apex adhe-
sions and by diaphragm adhesions in the lower
part of the thorax wall. After having introduced
the galvanocauter in the pleural cavity I arrive at
the second and most difficult part of the opera-
tion, namely the handling of the galvanocauter
under guidance of the thoracoscope. It is by this
you want most practice. It is neither always quite
easy to find the very galvanocauter itself, and its
directing and aiiplying on the adhesion requires a
certain experience. Generally I apply the plati-
num needle on the narrowest part of the adhesion.
In the cases where a cavern in the lung exists just
under the attachment of an adhesion, I perform
the cauterization as near the chest wall as possi-
ble. The pain can hereby at the very cauteriza-
tion become rather severe. But as a rule the
pains are quite moderate, especially when the
question is about small strings or membranes
which easily are cauterized in a part of a minute.
Thick, firm, sinewy adhesions offer sometimes a
very strong resistance, and I have now and then
worked with them for one or two hours. At the
cauterization it is of great importance not to have
too strong a glow on the galvanocauter, because
otherwise a hemorrhage may arise. Only in one
of my fifty-five cases has a hemorrhage of 100-
200 c.c.m. appeared and from other authors who
have used the method only one single case is
known to me where a really life dangerous hem-
orrhage appeared, probably caused by too strong
glow. Since no death caused by hemorrhage m
these more than 100 cases has occurred it seems
to me that we are entitled to consider this compli-
cation not to be of such importance that the
operation ought therefore to be abandoned in
the same favorable cases. If a slight glow is used
the danger ought to be relatively small, even if a
curtain exists on this point.
At an epicritic survey of the fifty cases which
I published, I will first consider the complications
which ensued a shorter or longer time after the
operations. To begin with we have to consider
the large or small skin emphysema which origin-
ate at the punction openings of the chest. This
complication can cause trouble in a few days but
disappears then and is of no consideration to the
further development.
But of another and greater importance are the
pleuritic exudates which develop after the opera-
tion. I have in the following table arranged the
different possibilities which occurred in my cases.
1. Cases without exudate 25
2. Cases with slight exudate 15
3. Cases with long-lasting exudate and fever 4
4. Cases with long-lasting exudate, accompanied
by empyema 4
5. Cases with exudate appearing first 1 to 3
months after operation 2
Total 50
The first group of cases has quite naturally de-
veloped very favorably. After a few days’ fevei,
the patient has had the same temperature as be-
fore operation. The same can be said about
group two where we have a small exudate which
does not reach above the pleura cupola. In one
or two weeks it has disappeared without a trace.
These pleurisies have therefore no influence on
the clinical result and one is entitled to say that
the operation in four of five cases has had no un-
favorable influence on the clinical course. The
third group comprises four cases, in which the ex-
udate together with a higher temperature has had
an apparent influence on the general condition
which has remained during four to six weeks. To
judge from the whole an ordinary tubercular
pleurisy was at hand.
In the fourth group, which also comprises four
cases, the pleurisy, developing after the operation
was at first of a serous nature and thus of the
same character as in group three. A tubercular
empyema appeared after one or several months.
In these cases the complication has had a very
unfortunate influence, that of these four cases
three ended with death after one or two years,
without doubt in no small degree caused by the
weakened general condition through the chronic
empyema. In the last group the condition has
been good after the operation, but after a few
months an exudate has appeared which in both
cases turned to empyema. Both patients got nev-
ertheless by and by better so that the prospects
for the future are tolerably good. If the cauter-
ization has had anything to do with the later ap-
pearing pleurisy of course is impossible to decide
with certainty. An independent development of
the empyema is according to my opinion probable.
In other statistics one finds by Gravesen in two
VoL. XII, No. 11]
Journal of Iowa State Medical Society
435
cases empyema and in four cases serous pleurisy
from his sixteen cases. In Holmboes twelve cases
there is once a slight pleurisy and once a severe
acute pleurisy and empyema with mixed infec-
tion, by which the patient died after four to five
days. From above mentioned experiences taken
altogether is seen that the pleuritic exudate and
empyema are the most serious complications at
this operation. In my cases the mortality is about
6 per cent, which though is maximum and ought
barely to be attributed to the operation alto-
gether. On the other hand it is evident that this
complication nevertheless, is not of such an im-
portance that the use of the method ought to be
excluded from suitable cases.
I will now pass over to the credit side of the
method and will in the following tables show the
result in the cases operated by me. I have ranged
the results in three groups, according to the po-
sition of the adhesions in the chest cavity.
Number
Complete or for
collapse of the
In clinical
Un-
complete
of
luug sufficient
respect with
cauteri-
cases
cauterization
good result
zatioii
Jacobaeus — -
a Apex-
adhesions .
... 5
4
4
1
b Lateral
adhesions .
...42
32
30
10
c Diaphragme
adhesions .
... 3
3
1
_
—
—
—
Total
...50
39
35
11
Holmboe
...12
7
7
5
Gravesen,
Saugman....
...16
9
7
7
—
—
—
Total
...78
55
49
23
To begin with we have the apex adhesions.
They are mostly short and technically difficult
to reach with the galvanocauter. At the cauteri-
2ation very often pains are felt on account of the
proximity to pleura parietalis. In four cases out
of five the operation has technically succeeded
and also a clinically favorable result obtained.
The second group, lateral adhesions, comprises
the main part of the cases. In thirty-two of them
the operation technically succeeded and in all of
them except two also a clinically favorable result
was obtained. In these two an empyema with the
above mentioned consequences has developed.
In the third group, diaphragm-adhesions, the
technical difficulties have been that the patient
during the progress of the cauterization proper
must keep the breath, because otherwise the
adhesion is in constant movement. It is an ad-
vantage that in such cases the cauterization
is completely painless. In all the cases the opera-
tion has .technically been successful, but only m
one case has the clinical result been of value. The
lung has had extensive adhesions in the upper
part of the chest, which it has not been possible t J
remove by this method. The aim of the operation
has been, in removing the diaphragm-adhesions to
get a better compression of the lung in the upper
part of the chest cavity. This is according to my
opinion only possible in exceptional cases.
The total sum of cases with clinically successful
result is thus. Among the eleven cases in which
only incomplete cauterization has taken place I
have only in one had a severe protracted pleurisy.
With regard to other authors, Holmboe has in
twelve cases had seven clinically successful result.
In sixteen cases Gravesen had nine technically
.successful and of these seven bacil-free ones.
Two of the incomplete cauterized cases have
taken a change for the worse through empyema
and protracted fever. The probable cause seem
to be an attempt to extend the indications for
operation by burning off rather extensive adhe-
sions. It is thus in no wise unusual to come
across cauterizations in several seances, each of a
duration of one to two hours. It is evident that
the danger of exudate in such cases must be
rather great.
If we thus summarize the result of these up to
the present time published, seventy-eight cases we
find that in fifty-five of them, that is, about three-
quarters of all, it has succeeded by this method
technically completely to remove the adhesions
which prevented the complete colapse of the
lung. Naturally the clinical result is not so fav-
orable as only forty-nine, that is, two-thirds of
the total sum have been symptom free. If we
now return to the first table the practical result
would be thus, that in these cases of adhesions one
can improve them in such a degree that the future
prospects of health increase from per cent
and 11.1 per cent, respective to not less than 70.2
per cent. The mortality index would according to
the same table be from 66/d per cent and 86.7 per
cent respective to 23.4 per cent. Whether this m
reality was so in the cases hitherto operated on I
cannot say, partly because the time which has
elapsed since the operation is too short, and partly
because patients have been sent to different san-
atorias and their further progress has not been
under observation. A rapid survey of the facts
available now would give less favorable figures,
since they point to a death index of between 30
and 40 per cent., which, however, of course has
nothing to do with the operation itself. Many
factors surely enter into play. The most common
436
Journal of Iowa State Medical Society
[November, 1922
appears to have been that the patients were from
the poorer classes and therefore unable to get
proper nursing. The adhesion cases are often
more severe than those in which a complete col-
lapse is obtained.
Although it has not succeeded to get so good
health percentage as in cases of simple, not com-
plicated, pneumothorax without adhesions, this
method ought to have a permanent value in, it
may be, a limited number of pneumothorax cases
with string or membrane-like adhesions.
I will now give a description of some cases of
intrathoracic tumors, where the thoracoscope is
employed for the detailed diagnosis of respiratory
tumors and afterwards in most of the cases an
operation succeed with the best result by Dr. Key.
Case I. A man, twenty-three years old. The last
half year he had sometimes suffered from stitch in
the left side and on account of this he was admitted
to hospital. On x-ray examination a very large
tumor was found in the pleural cavity quite filling up
its posterior part. From the experience of earlier
cases pneumothorax was now established. We could
at x-ray examination only see the tumor, not its
connection to the lung. On thoracoscopy, now per-
formed, was seen that the lung was lying rather free
from the tumor, only quite slightly attached to the
same on the anterior side. Besides the tumor was
free upw'ards and laterally. Operation was recom-
mended to the patient and Dr. Key removed the
tumor by operation October 13, 1915. It was per-
formed without insufflation apparatus and succeeded
well. The proceedings afterwards were rather diffi-
cult but the patient has nevertheless since then been
quite well.
Case II. A man of twenty-eight years. More by
accident an intrathoracic tumor was discovered. Also
here pneumothorax was established and it was seen
that the tumor was separated from the lung. On
thoracoscopy a tumor, the size of a goose egg and
with a broad stalk was immediately found in Angulus
costarum.
Also this tumor was removed by Dr. Key, which
was done quite easily. The tumors in both these
cases were fibromyoma.
Case III. A woman, twenty-eight years old. The
patient got ill half a year before with cough and symp-
toms of bronchitis. The respiration over the left lung
downwards \vas weakened, fever set in and further
symptoms of exudative pleurisy. By x-ray examination
it was discovered that this was caused by a tumor. The
exudate was drawn off and replaced by air and thora-
coscopy performed, and now a large solid tumor,
tolerably free from the lung and the chest wall ob-
served. The surface was smooth with several lines
and a cyst the size of a bean. The pleural surfaces
were a little reddish with here and there greyish
white deposits; it was impossible to decide whether
they were fibrine or metastases. The exudate was
hemorrhagic and the exudate cells were microscop-
ically found to be of an endothelial type, thus point-
ing to malignant tumor. It was first after a rather
long consideration that we decided on operation. Dr.
Key performed this and it was rather difficult to re-
move the tumor, owing to the same at one place be-
ing attached to the aorta. The patient was very ex-
hausted after the operation but recovered quickly and
is now, four years after the operation, in perfect
health. As far as I know this is the first time that
a tumor with hemorrhagic exudate, with all clinical
symptoms of malignity, has been operated on with a
lasting good result. The tumor was from a patho-
logical anatomical point of view very peculiar. The
pathologists considered it to be xantosarcoma.
Case IV. Woman forty-seven years old. This pa-
tient, who always before had been healthy, called on
the doctor because of pains in the left shoulder and
left arm. By-x-ray examination a tumor was discov-
ered, which filled up the whole of the pleura cupola
on the left side. I want to point out that of clinical
symptoms not only the ordinary physical ones of the
chest but also the Horner symptom complex, that is
sympatheticoparalysis of the diseased side, could be
proved. Pneumothorax was induced, and the lung
was seen as an appendix of the tumor and seemed as
such to continue downwards. The thoracoscopy
confirmed that the tumor was situated intrapulmon-
ary. Thoracotomy was also performed but, as was
expected, the tumor was found to be inextirpable
because it had grown in into mediastinum.
Case V. Concerns a woman, forty-four years of
age, who was admitted to the hospital on account of
a slight haemoptysis. On x-ray examination this
formation was observed in the left lung. For the
rest an exhaustive examination gave a negative result
and the conclusion was drawn that this was an iso-
lated disease in the lung, either tumor or tuberculo-
sis, and the thought was directed on tumor diagnosis.
Echinoccocos do not exist here. Pneumothorax was
induced and thoracoscopy also performed without
any other result. Dr. Key removed the tumor which
proved to be a solitary tubercle. The diagnostic mis-
take in this case was however fatal as a tubercular
pleurisy with tubercular infection of the thorax wall
ensued. The patient got worse and died in a short
time.
The interest in these cases centers naturally
around the use of pneumothorax and thoraco-
scopy for the local diagnosis of introthoracic
tumors. In cases of pleuritic exudate Brauer in
Hambury has as the first one shown, that on
x-ray examination after the drawing off of the
exudate and its replacement by air, more beautiful
and more pictures of existing tumors are obtained
than when the exudate remains. The above re-
lated cases mark only the further development of
this observation since here pneumothorax has
been established in cases without exudate which
then have been subject to x-ray examination and
VoL. XII, No. 11
Journal of Iowa State Medical Society
437
thoracoscopy. In our summary Key and I have
arrived at the following results;
1. For the diagnosis and localization of pleural
and lung tumors, it is of great importance to
make an x-ray examination before as well a?,
after the induction of pneumothorax. By making
an x-ray examination after the induction of
pneumothorax valuable information is obtained,
which completes that already obtained by the
x-ray examination made before the induction of
pneumothorax.
2. By thoracoscopic examination valuable in-
formation is obtained for the diagnostic and local-
ization of pleural and lung tumors, which suc-
cessfully completes the result of x-ray examin-
ation.
3. If there is no opportunity of using a pres-
sure differential apparatus, it might be advan-
tageous to include pneumothorax previous to the
operation in the pleural cavity.
4. If pressure differential apparatus be em-
ployed, then pneumothorax for the thorascopical
examination ought to be induced as shortly before
the operation as possible, in order that the infla-
tion of the lung after the operation may not be
rendered more difficult or impossible.
5. If the lung is inflated after the operation,
more favorable conditions for the course of heal-
ing are eventually obtained.
CHRONIC APPENDICITIS*
Treatment and Complications Following
Operations
Ceorge Kessel, B.A., M.A., ?^I.D., F.A.C.S.,
Cresco
The management of appendicitis is a good deal
like the management of an automobile. There
are many surprises in waiting. You think the
thing is fixed, get in and pull the lever, yet it
will not go. You take out an appendix, wash your
hands, congratulate yourself that everything went
off well, but it will not go. The patient comes
back in three months and says, “Doctor, since my
operation I have more pain than ever.” Why .'
The auto didn’t go because your garage man
fixed the wrong wheel. The patient didn’t get
well because the surgeon fixed the wrong organ.
It was all a case of mistaken diagnosis.
Onh' a few years ago in the greatest clinic of
the world the long incision was denounced as
unscientific and dangerous; permissible only at
the post-mortem table. The short incision, the
’Read before the Austin Flint-Cedar Valley Medical Society
hily 21. 1921.
shorter the better, was eni])hasized as the on’v
safe one. It was not long, however, before the
change came. That same great surgeon in that
same great clinic soon began to bear from his pa-
tients with the short incisions. Then he began
to extend his incisions and to explore the ujijier
abdomen by simply putting his hand up inside the
abdomen and palpitating the region of the liver,
at the same time saying he questioned the safety
and wisdom of this procedure. What do they do
now in that great clinic ? It is not an uncommon
sight to see the abdomen laid open from the
xiphoid to the pubes, if it is necessary, to find
out what is the matter inside. They tell us now
that a long incision will heal just as quickly as a
short one. Hernia is no more likely to follow the
long than the short incision. If it does occur the
hernia in the short incision will be the worse of
the two. And they are right. The teaching now
is that instead of a thorough exploration of the
entire abdominal cavity being unscientific and
dangerous, the omission of this complete explora-
tion is unscientific and dangerous. Therefore,
the first requisite in abdominal surgery is an in-
cision long enough to permit a thorough explora-
tion of the entire cavity.
Chronic Appendicitis
When the character of appendicitis in its acute
form is better understood, it is probable that the
chronic type will be less frecjuently seen than it is
at present. IMany cases of chronic appendicitis
are based on previous acute attacks in which spon-
taneous improvement has taken place or which
have yielded to rational treatment, consisting of
complete physiologic and anatomic rest, ice bags,
etc.
If the surgical treatment could always be quick
there would be little chance for death. If the
physician would .say, “This is appendicitis and not
a case for me, but for the surgeon,” there would
be much less loss of precious time and much less
loss of life. This applies to chronic appendicitis
as well. If the surgical treatment could always
be quick there would be little chance of death.
The puzzling thing about appendicitis is its pro-
tean character. This is especially true of the
chronic disease. With the more general recogni-
tion that chronic appendicitis may stimulate any
one of the diseases of the abdomen, not excluding
genito-urinary and pelvic disorders, there is no
doubt that much less unnecessary surgery will be
done. Most commonly the disguise is that of
some disease of the upper abdomen, particularly
cholecystitis and duodenal or gastric ulcer. \"a-
rious concise terms, such as appendicular gas-
438
Journal of Iowa State Medical Society
[November, 1922
tralgia or appendical dyspepsia, have been sug-
gested to designate this deceptive type of chronic
appendicitis, but it is preferably called “appen-
dicitis with referred symptoms.”^
Dr. Bevan states his view of chronic appendi-
citis as follows : “There is one phase of this
question that I should like to discuss with you,
and that is the so-called cases of chronic appen-
dicitis, those cases that have never had an acute
attack, but which are supposed to have a chronic
infection in the appendix giving rise to slight dis-
tress in that region. I want to state my opinion
on this subject very strongly, and it is that most
of these cases are mistakes in diagnoses and not
cases of appendicitis at all, and, personally, I do
not recognize such a condition as chronic appen-
dicitis which has never given ri.se to any acute
symptoms. Almost invariably these cases are
cases of colitis, constipation, associated often with
the taking of carthartics, and clean up under med-
ical management. Show me'a clinic where any
considerable proportion of the appendicitis opera-
tions are done for so-called chronic appendicitis,
and I will show you a clinic where a large amount
of unnecessary operating is being done.”-
S Y M PTO M ATOLOG Y
If there is anything in the symptomatology of
a chronically diseased appendix it is found in the
extreme variability of the dyspepsia and the lack
of regularity in the evolution of symptoms. Arti-
cles of food that at one time are associated with
indigestion may be eaten with zest and relish on
other occasions. The mechanism in the produc-
tion of the symptomatology in the large majority
of cases is probably that of pylorospasm, wdth
])ain, increased secretion, increased acidity, gase-
ous and sour eructations, and occasionally vomit-
ing. This variability, in so far as its diagnostic
jMDSsibilities are concerned, may be found epi-
tomized by the statement of Moynihan that the
most frequent site of ulcer of the stomach is in
the right lower quadrant.
“Appendix dyspepsia” is a varied and indis-
tinct clinical picture. It is usually more difficult
to diagnose than either the conditions of ulcer or
disease of the gall-bladder. If one can eliminate
either of the two conditions named above it
.should be possible to arrive at a diagnosis of ap-
j)endicular dyspepsia by elimination. In the or-
dinary case there is usually an absence of a his-
tory of an acute attack. Epigastric distress is a
.source of intermittent annoyance or sense of ache,
and usually with no distinct relationship to food.
The i)ain or distress is apt to be aggravated by
activity and motion and is occasionally relieved
by an enema or a cathartic. It is infrequent for
appendicular dyspepsia to be associated with a
history of acute attacks, although occasionally lo-
cal appendical j>ain may be elicited.^
Some of the visceral diseases with which ap-
pendicitis is commonly confused and oftentimes
associated, are duodenal ulcer, gastric ulcer, and
cholecystitis, with or without calculus, and renal
as well as pelvic disorders.^
It is also necessary to establish clearly that we
are dealing with an intra-abdominal irritation,
because it is estimated that 40 per cent of the in-
digestions are due to causes extrinsic to the stom-
ach but within the abdomen and 40 per cent are
due to causes entirely remote from the abdomen.
Numerically the most frequent cause of indiges-
tion is : first, heart disease ; second, phthisis ;
third, anemia and chlorosis; fourth, neuroses or
psychoneuroses; and fifth, chronic nephritis.
The.se conditions are all remote from the abdomen
and can be eliminated.
Diagnosis
The question of chronic appendicitis calls for
attention not because of the high mortality rate
but because of a rather disconcerting morbidity
rate, a post-operative persistence of symptoms.
When a patient complains of the same symptoms
after appendectomy as before operation, there is
sufficient reason for belief that the original symp-
toms were not caused by the appendix — that treat-
ment was based on an incorrect diagnosis.^
Cases of chronic appendicitis in which stom-
ach symptoms predominated have been a stum-
bling block in the past and today the symptomat-
ology' of the condition is far from being definitely
settled. It has been noted that chronic dyspepsia
has been cured in patients who for years have
been treated for chronic stomach disorders, in
whom an acute appendicitis necessitated opera-
tion.^
Recognition of chronic appendicitis presents
many difficulties, because its own manifestations
are so variable and because so many conditions
simulate it.
Chronic appendicitis is too often suspected as
an adequate explanation for obscure digestive
ailments — much more often than is justified by
the fact.
The object of all diagnosis is rational treat-
ment, and once chronic appendicitis is diagnosed
there is no cure but surgery.®
It seems the time has come when the diagnosis
of chronic appendicitis should no longer be made
by the doctor off-hand in his private office, but
he should call in aid from the laboratory, and
VoL. XII, No. Ill
Journal of Iowa State Medical Society
439
only after a searching history taking and exclu-
sion of all other diseases may a fairly correct
diagnosis be made.
Treatment
'rreatment in chronic appendicitis will scarcely
bear discussion. In ulcer of the stomach we do
have medical cases in greater number than sur-
gical cases. In gall-bladder diseases we may be
pardoned for advising some sufferers to take the
Carlsbad cure or other methods of treatment that
may influence the oncoming of the later stage, but
chronic appendicitis can only justly fall to sur-
gery, and any other advice when the diagnosis is
made must be considered faulty and perhaps dan-
gerous.^
Appendicitis, either acute or chronic, or an ap-
pendix that has been the site of an unquestioned
inflammation, calls for surgical treatment.
Pseudo-appendicitis is in no way related to the
appendix and is a non-surgical condition. Every
case of so-called chronic appendicitis that is as-
sociated with enteroptosis, constipation and symp-
toms of nervous instability should be looked on
as pseudo-appendicitis until the history and clini-
cal findings prove it to be otherwise. If operation
is decided on, it should be exploratory.'*
Xo disease is more ideally suited for surgical
treatment than is chronic appendicitis. The oper-
ative dangers are practically nil and if the diag-
nosis is correct the post-operative cure is abso-
lute. A correct diagnosis is the all essential factor
for success. The only absolutely reliable test for
the purpose of studying the symptomatology of
this disease, is the end result record. The patient
who is promptly and permanently relieved follow-
ing a simple appendectomy did have appendicitis.
The patient who is not cured following the oper-
ation in all probability did not have an appendix
which was responsible for the symptoms. Dr.
.Stanton’s end result records studied extended
over ])criods of from one to ten years following
operations. His conclusion is that chronic ap-
pendicitis has proved to be a rather sharply de-
fined disease in which the symptoms mav be rec-
ognized by the fact that they reproduce in minia-
ture the first symptoms of the acute attack. The
disease differs from acute appendicitis by the
fact that the obstruction is incomplete or because
it is habitually relieved before the acute inflam-
matory stage develops.’
( Dr. Heyd’s statement) — It is interesting to
note that the cases that we have operated upon
for chronically diseased appendices and whose
only comjdaint was pain in the right lower quad-
rant have, as a rule, not been uniformly benefited
by the operation. Where we have corrected a
dilated or atonic cecum or done a cecoplication
and, more rarely, cecofixation, or have attended
to a gross pathologic change in the cecal region
or in the tube and ovary, these cases have been
cured of the jiain in the right lower quadrant, but
where a simple appendectomy has been done for
the sole complaint of pain in the right lower
quadrant we have been chagrined to find that
these patients have not been cured by an ap-
pendectomy. .\ccordingly, a symptomatology em-
bracing only jiain in the right lower quadrant
without any other confirmatory sign is usually
not the type of abdomen that is going to be
cured of its pain by an appendectomy. On the
other hand, cases that have had a subacute attack
of appendicitis with so-called appendicular colic
of epigastric pain, nausea, eructations or vomit-
ing, and then a subsidence. of the symptomatology',
have been uniformly cured by the removal of the
appendix.®
Appendectomy as a routine measure when oper-
ating for intraabdominal disease is undoubtedly a
justifiable and warranted procedure and steadily
gaining in favor among surgeons.
Appendectomy is probably the safest operation
in the surgeon’s repertory. The mortality in un-
complicated cases of appendicitis is about one-
half per cent or less, the liability is minimal, and
the results, beyond question, beneficial. It looms
large as an important contributing factor in pre-
ventive medicine, the watchword of the profes-
sion today.*
Post-Operative Complications
( r ) Right Inguinal Hernia.
In a study of 795 operations for right inguinal
hernia, performed in the Mayo Clinic, seventeen
had previous operations for appendicitis.
It is evident that the short McBurney incision
for the removal of a chronic appendix cannot
carry great risk of injury to the nerve-supply of
the muscles of the inguinal canal, since the fre-
quency of such operations would mean that more
hernias would develop at the internal ring as a
secondary result than have heretofore been re-
ported. It is equally true, however, that when
considerable traumatism to the abdominal wall
has occurred at the time of operation by stretch-
ing and traction, or when drainage has been neces-
sary, enough damage may have been done to the
nerve-trunk to cause a deficiency of nerve supply
to the muscles and a consequent atrophv of
greater or less degree.
Conclusion: A McBurney incision which
damages the nerve-trunks supplying the muscles
440
Journal of Iowa State Medical Society
[November, 1'922
at the internal ring may be followed by right in-
guinal hernia. This damage is usually dependent
on the use of drainage and infection of the ab-
dominal wall. The sequelae in all probability, oc-
cur in individuals who are already predisposed to
hernia by the presence of a latent sac.®
(2) Mesogastric Manbrane.
Illustrated by a case by Dr. Taylor:
Patient, a young woman of twenty-two, in or-
dinarily good health up to 1913, when she began to
suffer from periodic sick headaches which became
more frequent and disabling. After two years her
physician decided she was suffering from chronic
appendicitis with reflex disturbances of the stomach.
Appendix was removed. The removal of the ap-
pendix gave no relief, but in addition to her previous
troubles there was a steady dull pain in the right ab-
domen which seemed to have no relation to the tak-
ing of food; she was not troubled with gas formation
or constipation; had not lost weight; pain was made
worse bj- standing, and somewhat relieved by sitting
in a crouching position or lying on her stomach. An
abdominal belt gave some comfort but no real re-
lief. Attacks of headache and vomiting became more
frequent and so severe as to interfere with her work.
X-ray showed high fixation of the duodenum, gas-
troptosis and coloptoses. Operation was performed.
The duodenum was found to be held fast to the gall-
bladder and the cystic duct by a firm fold of peri-
toneum which ran forward half way to the fundus
of the gall-bladder, continuous with the edge of the
lesser omentum. This double layer of peritoneum
was divided with the scissors with practically no
hemorrhage. The membrane was divided and the
duodenum mobilized sufficiently to form an easy
natural curve from the stomach outlet. A firm adhe-
sion of the omentum to the appendix scar was also
found and divided. Xo Jackson’s membrane was
present. Stomach showed no abnormalities. Un-
eventful recovery. Patient perfectly well.
Thi.s condition of mesogastric membrane had
been described by seteral men previously but
more thoroughly by Dr. Harris in a paper pub-
lished in The Journal of the American iMedical
Association seven years ago.^®
End Results
In 1911 Dr. Stanton reviewed his end results
(.-\nn. Sttrg. 53:813, 1911 ) but states that theie
was an error in diagnosis amounting to 36 per
cent. During the pa.>t eight years 86 per cent
of the operated patients have been cured of
chronic appendicitis. The great majority of the
uncured patients presented at operation a normal
appendix and an enlarged movable cecum ; these
])atients complain of right inguinal pain associated
with varying degrees of constipation, but a care-
fully taken history fails to reveal the first two
cardinal symptoms of appendicitis, namely the
cramplike, diffuse, or midabdominal pain and
nausea. Author says he has never cured a sin-
gle one of these patients by appendectomy nor
has he learned of a convincing cure by other sur-
geons. These patients are readih- relieved by
proper corseting, abdominal exercises, hygiene,
and cathartics. Operations undertaken in the
hope that the appendix might be the cause of va-
rious obscure gastrointestinal symptoms have been
failures. Such authorities as Ewald and Moyni-
han have asserted that almost every conceivable
form of dyspepsia might be caused by the ap-
pendix ; author hoped they might be right, but to
date has failed to find the cases. ^
The Lesson
What is the lesson ? The answer is that sur-
geons, always mindful of the high standard of
their calling, should consider the appendix in-
nocent until it is proven guilty by a critical an-
alysis of all the clinical evidence, for and against,
before deciding on operation.
BIBLIOGRAPHY
1. Deaver, John B. : Chronic Appendicitis — Med. Clin, of
X. A. 3:1167-1174, 1920. March.
2. Bevan, Arthur Dean: Appendicitis — Surg. Clin. 3:301-329.
1919. April.
3. Heyd, Charles Gordon: Chronic Appendicitis — Surg. Clin,
of X. A. 1:522-523. 1921, April.
4. Connell, F, Gregory: Pseudo-appendicitis — J. A. M. A.
67:335-.3.38, 1916, July 29.
5. Graham, Christopher and Guthrie, Donald: Dyspeptic type
of Chronic Appendicitis (pyloric spasm), with Differential Diag-
nosis— Mayo Clinic 1910:225-234.
6. Cheney, William Fitch: Diagnosis of Chronic Appendicitis.
Am. J. Med. Sci. 46:494-507. 1918.
7. Stanton, E. MacD.: Chronic Appendicitis: a Study of
Postoperative End Results — Xew York M. J. 110:406-409, 1919.
8. Heyd. Charles Gordon: Chronic Appendicitis — Surg. Clin,
of X. 1:524-525. 1921, April.
9. Balfour, Donald C.: Occurrence of Right Inguinal Hernia
Following Appendectomy — Mayo Clinic 1912:242-245.
10. Taylor. A. S. : Chronic Appendicitis — Ann. Surg. 71:222-
225. 1920.
11. Heyd. Charles Gordon: Chronic Appendicitis — Surg.
Clin, of X. .\. 1:521, 1921. April.
THE DIAGX(3SIS OF APPENDICITIS*
M. J. Kenefick, M.D., Algona
It may seem like a review of ancient history to
bring the subject of appendicitis before a medical
meeting at this time.
P>ut the fact remains that this serious disease i>
of frequent occurrence and as very little can be
said about its prevention we shall always be con-
cerned about its diagnosis and treatment.
The fact, also, that it is a disease first seen and
treated by the general practitioner or family phy-
sician, makes the subject one of vital interest to
a meeting like this, made up largely of general
practitioners.
‘Read before the .\iistin Flint-Cedar Valley Medical Society,
.Tuly 21. 1921.
VoL. XII, Xo. Ill
Journal of Iowa State Medical Society
441
The late Dr. John B. Murphy, one of the pio-
neer American surgeons to deal successfully with
this disease, said, a short time before his death,
that it is now time to review and rewrite the
whole subject. It is greatly to be regretted that
this great teacher did not live to complete this im-
l>ortant task. He performed his first operation
for appendicitis in Cook County Hospital in 1889.
As an introduction, I will quote his exact words
from one of his clinics in 1915.
“The average hospital mortality rate is just a
little over 10 per cent. These are not surgeon’s
.statistics, they are the statistics of hospital man-
agements, figures taken from the printed reports
of hospitals which are progressive enough to pub-
lish reports. They include appendicitis cases of
all classes brought to the hospitals for operation.
“Is it time to stop talking about appendicitis?
Xo. It is just the time to begin talking about
appendicitis and talking most seriously and em-
phatically about it.”
As in all disease which we are called upon to
treat, a correct diagnosis is of great importance.
It is especially so in appendicitis for upon a cor-
rect early diagnosis depends the successful treat-
ment.
For the purpose of this brief paper I shall re-
fer : ( 1 ) to the diagnosis of acute appendicitis ;
(2) to the diagnosis of chronic appendicitis.
In the large majority of acute cases the physi-
cian is called to the bedside of the patient. Cases
of chronic appendicitis usually consult the doctor
at his office.
What induces the patient to call the doctor
Pain in the abdomen, persistent pain which came
on suddenly perhaps awakening him from a sound
sleep or compelling him to quit work by day.
Many times the customary cathartic has been
taken before the arrival of the physician.
The patient’s only desire usually is to be re-
lieved of pain and here too often the physician
yields to temptation and gives a hypodermic of
morphine, thus masking the first and most im-
portant diagnostic sign. Here the physician is
justified in administering a placebo and watching
the development of the case for the next few
hours in case he should be called too early to
make a diagnosis on his first visit while the pain
is still diffuse.
While we are considering pain as the first and
most important symptom we must not forget that
the cessation of pain is a danger signal. ■
While it is not the purpose of this brief paper
to go into the pathology of appendicitis yet we can
not overlook the rapid changes which take place
within the abdomen in a few hours.
Here again 1 beg to quo^e from Murphy: “A
mild attack of appendicitis which starts out with
colicky pains, nausea and vomiting and a slight
elevation of temperaHire may develoj) a leukocy-
tosis and local sensitiveness of the right flank in
the first six or eight hours of the attack. By the
next morning the pain and temperature may be
gone entirely. The doctor then is in a quandary.
He is unable to tell from the symptomatology
whether the patient is going on to an uneventful
recovery because the contents of the affected ap-
pendix have drained into the cecum or whether
he is headed straight for the grave because the in-
fected appendix has undergone complete gan-
grene.”
“A gangrenous appendix causes no pain be-
cause its nerves are dead.”
“It produces no elevation of temperature or
leukocytosis because absorption of the products
of infection are impossible through its dead mu-
cosa. When an apparently mild attack of acute
appendicitis has reached such a stage, all the
doctor can be certain of is that the patient has
appendicitis. The disappearance of pain is the
last call to operation.”
“If the appendix is gangrenous the next symp-
tom will be that of a rapidly spreading and prob-
ably fatal peritonitis. Remember that the ap-
pendix which becomes suddenly completely gan-
grenous forms no adhesions, and when it ruptures
it empties its contents into a free and unprotected
peritoneal cavity.” The appendix which is dead,
like the patient who is dead, presents no symp-
toms. The living appendix is painful and absorbs
the products of bacterial infection, which produce
fever and leukocytosis.
But the dead appendix has no sensation and no
power of absorption. The patient with such an
appendix in his abdomen has no symptoms until
its necrotic wall ruptures and a spreading periton-
itis sets in.
There is another condition where cessation of
pain is a danger signal and that is in perforation
of the ordinary pus appendix. Perforation re-
lieves tension on a distended, inflamed appendix.
The cessation of pain is only a deceptive lull in
the storm which soon increases in severity with
local or general peritonitis.
The second symptom in sequence is nausea and
vomiting, the former always and the latter com-
monly present in severe cases.
The third symptom in order is local tenderness
and rigidity in the right iliac region. Muscular
rigidity is nature’s guard over the inflamed ap-
pendix. Marked rigidity of the right rectus may
442
Journal of Iowa State Medical Society
[November, 1922
be taken as a sign of a perforated appendix and
beginning peritonitis.
bourth, elevation of temperatures and pulse,
bormerly too much dependence was placed upon
these symptoms. Experience has taught us that
serious pathologic changes may be taking place
with a subnormal or normal temperature and
slight elevation of pulse.
Cases with elevation of temperature 101 to 102
preceding pain should practically rule out the
diagnosis. Surgeons of experience have operated
upon cases of typhoid fever with perforating ul-
cer under a diagnosis of acute appendicitis.
Cases presenting themselves with abdominal
pain or referred abdominal pain and with temper-
ature of 102 to 104 within twenty-four hours
from beginning of attack should be examined
carefully. Suspect pneumonia, especially in chil-
dren.
Leukocytosis is corroborative evidence in the
acute stage and the count should be always made
when possible.
In dealing with acute cases treated surgically
we are often surprised at the extent of pathologic
changes present. Formerly we dated the begin-
ning of the disease from the beginning of the
present attack. A careful history of the case will
elicit the fact that this attack is only an acute
exacerbation of a chronic condition persisting
for months or perhaps for years. In other words
we often find chronic appendicitis precedes and
leads up to acute appendicitis.
A\'hile the typical case of appendicitis is usu-
ally not difficult of diagnosis we must not forget
that there are typical cases.
The long list of diseases which have been mis-
taken for appendicitis should be a warning to the
diagnostician. The list is long and includes the
following which must be excluded when possible
in making a correct diagnosis: 1. Strangulated
hernia. 2. Perforation in typhoid fever. 3.
Tubercular peritonitis. 4. Cholecystitis. 5.
Pyosalpinix. 6. Renal colic. 7. Pneumonia,
especially in children. 8. Ruptured tubal preg-
nancy. 9. Acute gastrointestinal colic. 10. Per-
forating duodenal or gastric ulcer. 11. Twisted
pedicle of ovarian cyst. 12. Diverticulitis. 13.
Dietel’s crisis due to kinking of ureter in movable
kidney. 14. Hysteria.
I shall not attempt to go into the differential
diagnosis of all these conditions, but simply name
them that we may avoid some of these rocks upon
which others have been shipwrecked.
The Diagnosis of Chronic Appendicitis — As has
been stated these cases are of the walking variety
and come to consult the physician at his office
and many of them tax the skill of the most expert
diagnostician. Time can be taken for a careful
study of these cases and if this were done less
reproach would be brought upon surgery. Too
many cases of neurasthenia, hyperacidity, viscer-
optosis and hysteria have been operated upon by
ambitious surgeons who are afflicted with what
Nicholos Senn rightly named “furor operations”
or craze to operate.
In the diagnosis of chronic appendicitis a care-
fully taken history is o’f first importance. There
will usually be elicited a history of mild acute at-
tacks. Here an x-ray examination by a compe-
tent roentgenologist may be of much assistance.
Doubtful cases should be referred to internists
and surgeons of experience for diagnosis.
In conclusion the diagnosis of acute appendicitis
may be epitomized in three words, viz : pain,
tenderness, rigidity. Likewise the diagnosis of
chronic appendicitis by the signal at the railway
crossing: stop, look and listen.
THE RADIATION TREATMENT OF HY-
PERTHYROIDISM AND THE BASAL
METABOLISM TEST*
Harold Swanberg, B.Sc., M.D., Quincy, Illinois
Roentgerologist to St. Mary’s Hospital and Blessing Hospital,
Quincy, Illinois
The successful treatment of practically every
pathologic condition depends greatly upon an ac-
curate diagnosis and hyperthyroidism offers no
exception to this general rule. In order that we
may have a broader conception of this subject it
would be well to recall Plummer’s classification
of thyroid disorders (excluding the malignancies
and inflammatory conditions) which is as fol-
lows :
1. Too Much Secretion (Hyperthyroidism, Hy-
perthyroida or Toxic Goiter): Exophthalmic Goiter,
and Thyro-toxic Adenoma — Have an increased meta-
bolic rate.
2. Too Little Secretion (Hypothyroidism): Cre-
tinism and Myxedema — Have a decreased metabolic
rate.
3. No Altered Secretion (Simple or Non-toxic
Goiter): Non-toxic Adenoma, Colloid Goiter and
Adolescent Goiter — Have a normal metabolic rate.
The symptoms of hyperthyroidism are such
that no one of them is pathognomonic of the con-
dition and it is not rare to find all the cardinal
symptoms present in one not suffering from the
disease. If, however, the symptoms are inter-
preted in the light of a careful basal metabolism
*Read by invitation before the Physicians* Club, Keokuk, Iowa.
June 13, 1922, and the Hancock County Medical Society,
Carthage. Illinois, July 3, 1922.
VoL. XII, No. Ill
Journal of Iowa State Medical Society
443
study there should be little trouble in reaching an
accurate diagnosis. While the basal metabolism
test has been a wonderful aid in the successful
diagnosis of hyperthyroidism, many physicians
have developed erroneous ideas as to the general
usefulness of the test. The following remarks
in regard to the clinical interpretation of the test,
if carefully followed, will give a good general idea
of the significance of the test and how it should
be interpreted clinically. (The author acknowl-
edges his indebtedness to Prof. H. M. Jones, Ph.
D. Department of Experimental Medicine, Uni-
versity of Illinois, for much of the following per-
taining to the clinical interpretation of the basal
metabolism test.)
Clinical Interpretation of Based Metabolism Test
A physician receiving a report of the result of
a basal metabolism test made of his patient is in-
formed that the rate is plus 25 per cent or perhaps
minus 20 per cent, but frequently this means but
little to him. It should be recalled that the normal
basal metabolism has a range of from plus 10 to
minus 10 per cent, the same as the normal temper-
ature may vary from 97.5 to 99 degrees F. If a
metabolic rate is above plus 10 or below minus 10
per cent, and the test has been rechecked and care-
fully made after the patient has been suitably pre-
pared, this justifies the diagnosis of some path-
ological condition associated with an altered meta-
bolic rate, the seriousness of the pathology being
proportional to the extent of the alteration in the
metabolic rate.
The greatest usefulness of the metabolism test
is in the diagnosis of thyroid and pituitary dis-
orders. So much has been written about the
metabolism test in connection with goiter condi-
tions that many physicians believe the rate of
metabolism is influenced only in thyroid disor-
ders. \Yhile a very high percentage of all ab-
normal basal metabolic rates are dependent on an
altered function of the thyroid, there are other
conditions which affect the rate.
The basal metabolism test is useful in the fol-
lowing conditions :
A. The metabolic rate is increased in —
1. Hyperthyroidism, that is, exophthalmic
goiter or thyro-toxic adenoma (from plus 20 to
plus 40 per cent in mild, plus 40 to plus 60 per
cent in moderate, plus 60 to plus 100 per cent or
more in severe cases) . In non-toxic enlargements
of the thyroid (simple goiter), as non-toxic aden-
oma, adolescent goiter and colloid goiter, the rate
is normal.
2. Pernicious anemia (as high as plus 40 per
cent in some cases).
3. Leukemias.
4. Typhoid (mainly because of fever).
5. Later months of pregnancy and early in
the puerperium.
6. All fevers (from plus 5 to plus 10 per cent
rise in metabolism for each Fahrenheit degree rise
in temperature).
7. Hyperpituitarism, that is, gigantism or
acromegaly (up to plus 40 per cent).
8. Diabetes (up to plus 20 per cent in early
cases, although below normal after the patient
becomes emaciated).
9. Cardiac decompensation (up to plys 40 per
cent).
We can conclude from the above that if the
metabolic rate is plus 45 per cent or more, the
diagnosis is practically certain to be hyperthyroid-
ism. There is no other pathologic condition which
will increase the metabolic rate so high as this
disease. However, if the rate is from plus 15 to
plus 40 per cent the diagnosis is not necessarilv
one of hyperthyroidism. If, however, a blood
count eliminates a primary anemia, no sugar is
present in the urine, cardiac examination reveals
no decompensation, a febrile condition is elimin-
ated by the thermometer, and a physical examin-
ation is negative for pregnancy or changes pro-
duced by hyperpituitarism, then we are justified
in interpreting the increased metabolic rate as due
to hyperthyroidism. In actual practice we find,
however, that over 90 per cent of all abnormally
increased metabolic rates are due to a hyper- func-
tion of the thyroid.
B. The metabolic rate is decreased in —
1. Myxedema and cretinism, that is hypothy-
roidism (as low as minus 25 per cent).
2. Frohlich’s syndrome of pituitary origin
(about minus 25 per cent, although in Frohlich’s
syndrome of the eunuchoid type, from which it is
most often clinically indistinguishable, the rate i‘-
normal.
3. Pathological obesity of hypothyroid or hy-
popituitary origin. Although in .simple obesity,
(the obesity of laziness and big eaters) the rate
is normal. In the former, glandular therapy is
indicated, but in the latter, thyroid preparations
should positively not be used, since thyroxin in-
creases the combustion of muscle tissue instead
of fat tissue.
4. Extreme cachexia, as in tuberculosis, dia-
betes, prolonged starvation, etc., (as low as
minus 30 per cent).
5. Persons in perfectly normal health, but
running a slow pulse, say as low as 50, may show
a metabolism rate as low as minus 20 per cent.
Journal of Iowa State Medical Society
[November, 1922
6. Addison’s disease (about minus 30 per
cent).
Combinations of these conditions may give any
kind of a rate, that is, an emaciated tuberculous
patient with fever may be low on account of the
emaciation or high on account of the fever, or
normal on account of both variations counter bal-
ancing each other.
Since there are so many pathological condi-
tions which raise or lower the rate of metabolism,
the question often asked is : Why is the test used
only in diagnosing thyroid and pituitary abnor-
malities?' The answer is simply this : All of the
above named pathological conditions, excepting
those of pituitary and thyroid abnormalities, are
diagnosed far more readily by other more obvious
means. Who needs a metabolism test to recog-
nize leukemia, diabetes, cardiac decompensation
or a full term pregnancy?
However, suppose a clinician in a suspected
case of hyperthyroidism finds the metabolism in-
creased, say, plus 30 per cent. If the patient has
four degrees of fever at the time of the test, and
the clinician does not know that the metabolism
is markedly increased by fever he would be easily
misled into error in his diagnosis of hyperthyroid-
ism. Therefore, although we do not find a use
for the test in diagnosing most of the conditions
named above, it is absolutely necessary that we
bear in mind that these conditions influence the
metabolic rate.
On the other hand, we have no means of recog-
nizing a beginning hyperthyroidism in the pres-
ence of symptoms suggesting incipient tuberculo-
sis, or neurasthenia, or the neuroses of adole-
scence, excepting through the basal metabolism
test.
Likewise, the two types of Frohlich’s syndrome
can often be distinguished only by means of a de-
termination of the metabolic rate.
.Addison’s disease has often been confused with
myxedema, because of the pigmentation of the
skin observed in some cases of the latter, when
(if the low blood-pressure symptom is doubtful,
as from a complicating nephritis) the two can be
differentiated only by the therapeutic test, that is,
through thyroid therapy, controlled by successive
metabolism determinations.
Patients complaining of recent rapid gain in
weight can not be effectually treated until the
metabolism rate shows whether the condition is
that of the simple or of the endocrine type of
obesity. Having determined by the basal meta-
bolism test whether the condition is one of simple
or of pathologic obesity, the data obtained from
this may then be used to estimate the caloric or
dietetic control of the one, and the thyroxin or
thyroid gland treatment of the other.
The test is of the most value in the borderline
cases of hyperthyroidism, and while one seldom
requires the test for recognition of the more ad-
vanced cases, it is most often in the advanced
cases that the test is required to show how the
disease in each individual case responds, to treai-
ment — x-ray, radium, rest in bed, ligation, thy-
roidectomy— and also to indicate which form of
treatment in a given case is the better one to
employ at the outset.
Perhaps nothing is more striking than the use
of the test in determining whether or not the cor-
rect dosage of thyroxin or thyroid preparation is
being used in the treatment of myxedema, since
these preparations vary in strength from nothing
to full potency, and since individuals vary in the
amount of the drug they require to bring the met-
abolism up to the normal basal level.
.-Another question is often asked : Is it possible
to decide by the aid of the basal metabolism test
whether or not radical operations may be safely
undertaken in moderately severe cases of hyper-
thyroidism? Mayo (Surg. Gyn. and Obstetrics,
March, 1921) believes that a patient showing a
metabolism rate of plus 40 per cent is a more dan-
gerous risk surgically when the rate is on the up-
grade, than the one whose rate is plus 60 per cent,
with the rate on the down-grade, as shown by suc-
cessive tests, taken a few weeks or days apart.
Other factors, that is, the age, the state of nutri-
tion, condition of the heart, etc., are obviously
most important in deciding the question of opera-
tion.
Pathology of Hyperthyroidism
Before considering the treatment of hyper-
thyroidism it would be well to recall the pathology
of the condition. There may or may not be en-
largement of the thyroid gland. Histologically
there is an almost universal proliferation of the
glandular cells, an increase in connective tissue,
certain groups of lymphoid tissue scattered
through the connective tissue and enlargement
and multiplication of the blood-vessels. There is
also some disturbance of the lymph system indi-
cated by a lymphocytosis and decreased poly-
morphonuclear neutrophiles. and frequently an en-
larged spleen and lymph glands. In over 50 per cent
of the exophthalmic goiter cases there is some un-
due enlargement of the thymus. There is a hyper-
secretion of the thyroid from the increased blood
supply or to the activity of the new formed cells
or both. The fact that there is a lessened amount
of the normal colloid material present in the gland
and an increased amount of iodine in the blood, is
VOL.XII, Xo. 11]
Journal of Iowa State Medical Society
445
decidedly suggestive that the trouble is due more
to an altered secretion than a superabundance of
normal secretion. In other words the gland se-
cretes a toxic substance into the blood stream.
This toxic secretion gives rise to an increased
oxidation of the tissues and as a result more
oxygen is absorbed through the lungs than nor-
mally. The principal of the basal metabolism test
in this condition is simply to observe the time
which the individual takes to consume a definite
quantity of oxygen, according to the sex, age,
body surface area, etc. In an advanced case of
hyperthyroidism the individual will consume twice
the amount of oxygen that a normal individual of
the same sex, age and size would consume.
Radiation Treatment of Hyperthyroidism
In undertaking to treat this disease we must
consider medical, surgical and ray therapy. As
the etiology is still unknown, we must attack it
symptomatically and with regard to what is
known of the patholog)'. All sources of infection
should be removed and a prompt reduction in
symptoms must be secured because of the degen-
erative changes that are prone to take place in the
heart. Complete physiologic rest is of great im-
portance. There is no known drug which will de-
crease the metabolic rate outside of the opiates,
hence the futility of persistent medication alone
in this condition. Our efforts should be directed
at something which will decrease the vascularity
or destroy the new formed cells of the thyroid.
This can be effectively done by surgery', radium
or x-ray.
WTen we consider the pathology of the gland
and the action of radium and x-rays they would
seem to have a most certain place as remedial
agents. We again bear in mind that there is a
proliferation of the glandular cells, deposits of
lymph tissue through the thyroid, an enlarged and
active thymus and lymph nodes and we see that
the disease apparently is not confined merely to
the thyroid gland. If surgery be done a diseased
portion of the gland is removed and healthy thy-
roid tissue also taken away. In the portion left
behind, certain of the diseased elements remain to
often cause further trouble and perhaps to again
proliferate when the strain for caring for the
body is thrown upon the small remaining amount
of normal thyroid tissue, also the thymus gland is
not operated upon. We remember that there is a
hyperplasia of the arteries which the Mayos have
endeavored to attack by ligation but this does
not distribute the blocking process evenly through
the gland.
Radium or x-rays possess the ability to kill a
diseased cell or a new growth cell when several
times the same dose would be necessary to kill a
normal adult cell. Also when applied to a blood-
vessel there is a swelling of the tunica intima fol-
lowed by an obliterative endarteritis in the smaller
vessels and diminution of the caliber of the larger
ones. Now whether the toxic secretion be due to
the additional blood supply or to the activity of
the new formed cells in the gland, or to both, it
will be affected by the radium or x-ray action.
There is this further advantage in using radium
or x-i'ays, that while diffuse action over the entire
gland will eliminate the toxic cells yet the normal
healthy tissue will be left untouched, provided the
dosage can be accurately estimated. Further the
blood supply will be reduced much more evenly
throughout the gland than can be done by ligation
of some of the thyroid arteries.
We also see that radium or x-rays can be used
not only on a case suitable for a surgeon, but on
cases where the surgeon is compelled to decline
to operate and even on cases where the surgeon
has operated and failed. The thymus and lym-
phatic system can be, and are, rayed, which may
explain the success of radium or x-rays on a case
where operative removal of a part of the thyroid
has not been successful.
Soiland states, “It is not the intention of the
writer to decry surgery, or to detract one iota
from the many brilliant results obtained by com-
petent operators, but the fact must not be lost
sight of that in radiation we have a proved thera-
peutic agent, far superior to any other given us
up to the present time. The oft repeated state-
ment that radiation over any field creates so much
vascularity, or produces so many adhesions that
surgery is rendered more difficult is entirely
false. Radiation always diminishes vascularity in
any region where it is applied long enough to have
its obliterating effect on the arterioles established,
and this is the essential status required in the suc-
cessful termination of toxicity in this variety of
goiter. There is surely no longer any excuse for
denying a patient the use of this remedy, which
if not successful, has at least prepared the way
for possible surgery.”
Dr. Soiland’s statement should be qualified in
that, multiple raying of the thyroid with small
doses over a prolonged period of time will make
operation more difficult because of the resulting
fibrosis. However, there is little excuse for such
treatment. The proper treatment requires com-
parative few, but fairly large filtered doses. The
metabolism and pulse rate usually return to nor-
mal after six to eight x-ray treatments have been
given over a period of about six months. If x-ray
446
Journal of Iowa State Medical Society
[November, 1922
therapy is prescribed and four treatments are
given at three week intervals, and the patient has
not shown definite clinical improvement, nothing
is to be gained by further treatment, and the sur-
geon can operate the goiter without any attending
difficulties as a result of this previous radiation.
No less of an eminent surgeon than Crile of
Cle\ eland has shown that x-ray therapy in hyper-
thyroidism reduces the basal metabolism more
than ligation. However in fairness to Crile it
should also be stated that he contends that bi-
lateral partial thyroidectomy reduces the meta-
bolism more markedly than x-ray therapy.
.\s far as the author’s- personal experience is
concerned, it makes very little difference whether
radium or x-rays are emjiloyed. They both give
equally good results.
Conclusions
I believe radium or x-rays should be given a
trial in hyperthyroidism because;
First — There is no mortality.
Second — There is no resulting scar or hospital-
ization.
Third — It is painless and causes very little in-
convenience to the patient.
Fourth — It does not interfere with the patient’s
occupation.
Fifth — The thymus can be treated which is im-
practical to attack surgically.
Sixth — Surgery in removing proliferating cells
leaves others behind, and by ligating still leaves
some of the blood supply more or less undis-
turbed. The selective action of the radium or
x-rays to a much greater degree destroys the
harmful cells, while not disturbing the normal
cells, and also causes a much more symmetrical
diminution of the blood supply.
Seventh — It can be used in cases where surgery
fears to venture or has failed.
Fighth — If not entirely successful, an operation
may be performed with less danger because of
the favorable action of the rays on the thymus.
In nearly all such cases the preliminary opera-
tions of multiple ligations can be dispensed with
and the final operation of partial thyroidectomy
done at once. No greater service can be rendered
a patient than to save him these multiple opera-
tions with their attending dangers.
731 Hampshire Street.
BIBLIOGRAPHY:
1. Claggett. X.. "Treatment of Goiter with Radium.” Il-
linois .Medicarjournal. 38:318, October. IhiO
2. Soiland, .Mbert. "Radiation and Thyroid Disease.” Journal
of Radioiogy, 2:19. July. 1921.
3. Crile, G. W.. "Surgery versus Roentgen Ray in the Treat-
ment of Hyperthyroidism.” J. M. .\.. 77:1324. October 22. 1921.
4. Swanberg. Harold. "Principles of the Basal Metabolism
Test.” Illinois lledical Journal. 41:1.5, January, 1922.
5. Jones. H. M.. "Control of X-Ray Therapy in Hyperthyroid-
ism by the Basal Metabolism Test,” Journal of Radiology, 3:85,
March, 1922.
OPHTH.\LMOLOGY AND THE LESSER
ALCOHOLS
James ]\E Downing, M.D., Des Moines
Since the eighteenth constitutional amendment
became effective, the medical and sociological
problem of alcohol has assumed a different as-
pect. It is not the purpose of this paper to dis-
cuss the time worn actions of ethyl alcohol but the
toxic effects of the lesser alcohols and raw liquor
especially on the .system in general and the eye in
particular.
The use of alcohol in one form or another ante-
dates history. In the ninth chapter of Genesis is
recorded the fact that Noah became drunken,
and all the ancient nations were known to be
heavy consumers of various alcoholic liquors.
When alcohol is mentioned we usually think of
the most used ethyl variety, however, in the fer-
mentation and malting of grains or fruits, several
other alcohols are produced, and it is these with
which I wish mostly to deal.
In the fermentation of fruit juices, and malting
and brewing of grain traces of methyl, ethyl,
propyl, butyl and amyl alcohols are developed,
depending for their proportion on the character
of the substance used and the method of fer-
mentation.
Baers table (chart) shows the relative toxicity
of the various groups. This table is relative, and
gives the immediate and not late toxic action of
the different alcohols.
SUBSTANCE
FORMULA
Boiling
Point
Specific
Gravity
Relative
Toxicity
“Baer”
Relative
Toxicity
on Fish
Picaud’
Methyl ....
.... CH30H
66°
0.812
0.8
0.66
Ethyl .......
....C2H50H
O
00
0.806
1.0
1.00
f’ropyl .....
....C3H70H
97°
0.817
2.0
2.00
Butyl .......
....C4H90H
117-'
0.823
3.0
3.00
.\mvl
..C5H110H
131"
0.825
4.0
10.00
It will be noted that ethyl alcohol is more toxic
than methyl. This is true only in so far as the
immediate dosage is concerned, and does not take
into consideration the late effects of methyl al-
cohol.
IMethyl alcohol is prepared commercially by the
destructive distillation of wood, but is present in
small amounts in ordinary fermentation.
-Presented before the Seventieth Annual Session, Iowa .State
Medical Society, Des Moines. Iowa. May 11, 12, 13, 1921,
Section Ophthalmology, Otology and Rhino-Laryngolo.gy.
VoL. XII, No. Ill
Journal of Iowa State Medical Society
447
Ethyl alcohol, the one chiefly used in medicine,
is derived from the fermentation of fruit and
grain sugars.
Propyl and butyl alcohols occur as by-products
in the fermentation of ethyl alcohol. Propyl is
more powerful than ethyl, and butyl more toxic
than propyl. Both occur as constituents of fusel
oil.
Amyl alcohol, the most toxic of the series, oc-
curs as a product of the yeast cell and is derived
from proteins. Amyl alcohol is the main constit-
uent of fusel oil, and is much used in the manu-
facture of essences and perfumes. For commer-
cial purposes it is derived mainly from the fer-
mentation of potatoes.
Any mash fermented with yeast from grain or
potatoes will contain a higher percentage of fusel
oil than the ordinary fermented fruit juices.
Picauds table of experiments of fish gives the
relative toxicity of the various groups.
In the manufacture of alcoholic liquors, there
are two main groups. The fermented type and
the distilled. Wines, champagnes and malt li-
quors are the fermented variety, and can contain
no more than 12 or 14 per cent of alcohol, unless
artificially fortified as the ferment is killed by
this percentage of spirits.
In the brewing of beer, yeast is used and by its
action on the protein of the grain, fusel oil is de-
veloped. This process was controlled by the ex-
perienced brewer by the length of time the yeast
was allowed to act, and also by the regulation of
the incubation temperature.
In the manufacture of home-brew, these factors
are not taken into consideration as accurately and
consequently, more injurious by-products are de-
veloped.
The distilled liquors including whiskey, brandy
or cognac, gin and rum, contain from 30 to 35
per cent of spirits.
Whiskey is manufactured by the distillation of
fermented grain mash; gin the same with the ad-
dition of juniper berries; rum from molasses, and
brandy from fermented fruit juices.
If the boiling point of the various alcohols be
noted, it will be seen that fractional distillation
could be carried out very nicely, to avoid contam-
ination of the finished liquor with the more toxic
alcohols.
In the distilleries the practice of manufacturing
li([uor was a fine art. They emploved expert
chemists and distillers and furnished a finished
product of uniform density and alcoholic content.
There was always a trace of fusel oil with its high
toxicity, but thi;- was eliminated by the ageing in
wood of all liquor before .sale, ddiree years was
a minimum for the ageing of all distilled liquor.
During this ])eriod the fusel oil became oxidized
into the esters and ethers of the fusel oil radicals
which gave the liquor its aroma or boquet.
In the corn variety, and the home distilled li-
quors of today, no check is made of the fermenta-
tion of the mash as regards formation of fusel
oil, no record made of the temperature at which
distillation is to be carried out to avoid distilling
over the heavier alcohols and needless to say, no
three year ageing in wood is permitted before the
article is on the market and consumed, as moon-
shine and white mule.
Even in the fermentation of wines, the amateur
develops a product much more toxic than the ex-
pert and experienced manufacture. Most of the
home-made wines are never six months old be-
fore consumed, and practically none of them
were kept in wooden containers that as much a?
])ossible of the fusel oil might be absorbed before
consumption.
Many of the favorite recipes for home-made
liquor call for the addition of yeast to the fruit
juices with the addition of sugar, corn meal and
other ingredients.
It will be readily understood how the excessive
development of the fusel oil series will be accord-
ingly increased.
It is to the fusel oil with its content of propyl,
butyl and amyl alcohols and the methyl content as
well, that these liquors owe their excessive kick.
The ordinary aged liquor when consumed gives
the reaction that most all are familiar with. But
the home-made variety, and particularly the home
distilled and corn liquor, have a long delayed
toxic action which must be attributed purely to
the high content of fusel oil.
I Prolonged hangovers, after a debauch of these
liquors, with the gastrointestinal and cardio-vas-
cular symptoms, we have all met with in the last
two years.
Bearing in mind the high fusel oil content of
raw liquor, it will be readily understood why con-
tinued use produces all the symptoms of chronic
alcoholism; with the gastro-intestinal, cardio-
vascular, renal, hepatic and neurological pathol-
ogy, much more rapidly than the aged in the wood
and blended varieties.
Then it must be remembered that all bootleg
whiskey is not distilled. Much of it is artificially
made from alcohol or denatured alcohol with
water, caramel coloring and flavoring. Liquor
of this type has been manufactured for years,
and marketed at a low rate, and its effects have
448
Journal of Iowa State Medical Society
[November, 1922
always been pernicious. But recently with the
difficulty in securing grain alcohol, the denatured
variety has been used with dire results to the con-
sumer. Almost daily one reads of serious com-
plications or death following the use of these il-
licit liquors.
Hundreds of deaths have been reported and
what from a sociological standpoint is much
worse, hundreds of cases of blindness have re-
sulted. The fact that a man goes on a debauch,
drinks raw or methyl spirits and dies, is his own
lookout, but when he becomes a burden on so-
ciety, a toxic amaurosis, it is entirely a different
matter.
It has long been known that methyl alcohol has
a peculiar and selective action on the optic nerve.
Casey Wood in 1904 published a most valuable
article on the action of methyl alcohol, and since
that time it has had periodic attention in the lit-
erature, and following the passage of the Vol-
stead act medical literature is full of case reports
and articles dealing with the subject.
Methyl alcohol, on account of its cheapness has
been heretofore used in the preparation of ex-
tracts. Fortunately, this process is now illegal
but the denaturing of ethyl alcohol with it still
continues. Until recently 10 per cent of methyl
alcohol was used as a denaturing agent, and it w’as
in that percentage that we purchased it at garages
and drug stores. On January 8, 1920, the regula-
tion was changed to 2 per cent, so the dangers
from a single drink of denatured alcohol now are
less remote. However, we cannot be so hopeful
in regard to the chronic ingestion of denatured
alcohol for the accumulative action of repeated
small amounts of methyl alcohol culminate in de-
fective vision and blindness.
iM ethyl alcohol has a selective affinity for the
highly specialized nerve elements, the optic in
particular.
Birsch-Herschfeld states that methyl alcohol
is capable of injuring the eye more severely and
rapidly than ethyl alcohol and that blindness en-
sues not only after an acute intoxication but after
repeated small doses, the result of which does
not occur in ethyl alcohol.
The cumulative effects of methyl alcohol are
marked. Fatty degeneration of the liver was al-
ways present in the animals under experimenta-
tion.
The cumulative action and the toxicity of
methyl alcohol, may be explained by the differ-
ence in the oxidation products in the animal or-
ganism.
Ethyl alcohol, although the more toxic in
acute stages, is rapidly oxidized into C02 and
water, and eliminated. IMethyl alcohol is slowly
and partially oxidized in the animal tissues and
split into substances more toxic than the alcohol
itself, namely formaldehyde and formic acid.
Formaldehyde is thirty times as toxic as methyl
alcohol and formic acid six times. Formic acid
is slowly excreted in the urine, and on test ani-
mals the maximum amount did not appear till the
fourth day after ingestion, showing how difficult
it is for the organism to eliminate these sub-
stances, and the prolonged toxic action.
Methyl alcohol is not only poisonous as a bever-
age, but the fumes when inhaled, give rise to the
same symptoms.
Shellac workers where wood alcohol is used
are liable to methyl poisoning. Cases have been
reported from the use of denatured alcohol fur
external use such as alcohol rubs after baths.
In the early intoxication from wood alcohol,
there is no particular symptom, there is no par-
ticular visual disturbance. The acute intoxica-
tion may pass away and no visual disturbance be
noted, then after several hours severe gastroin-
testinal symptoms arise, associated with rapidly
failing vision. Complete blindness and marked
dilitation of the pupils may occur but usually
there occurs marked improvement in the sight
for several days. Good useful vision may be re-
gained and continue for several weeks, then the
vision begins to fail the second time and usually
becomes as bad as in the beginning. This second
blindness is permanent and cannot be limited or
checked by treatment at that late date.
Very few cases come under treatment early
enough to give good results. The ordinary man
refuses to admit the alcoholic excess and probable
ingestion of bad liquor until it is too late to regain
the lost vision.
The late gastrointestinal symptoms, and de-
struction of vision, are due to the partial oxidiz-
ing of the methyl alcohol into formic acid and
formaldehyde and their action on the central ner-
vous system direct. The failure of vision is ac-
counted for in the same way. The early loss of
vision, to an acute toxic neuritis with resulting
pressure and pallor of the optic discs. The im-
provement in vision is due to the passing of the
neuritis and relief of tension. Then the second-
ary loss of vision due to secondary atrophy from
the dying nerve fibers.
Graefe-Saemish states that many of the autop-
sies showed the lesion beginning in the region of
the optic canal. Describing the secondary changes
he further states that it is a process of simple
VoL. XII, No. 11]
Journal of Iowa State Medical Society
449
atrophic degeneration both ascending and de-
scending, secondary to interstitial optic neuritis.
The manner and pathogenesis of failure of vi-
sion from the chronic ingestion of methyl alcohol
occur in the same way from its cumulative action
and also by its action on the ganglia cells.
The objective symptoms are not absolutely
pathognomonic. In the early stages the dilated
pupils and swollen disc, later the gradual develop-
ing palor of the nerve head and contraction of the
blood-vessels, giving the picture of a secondary
atrophy.
Perimetric findings will show an indefinite cen-
tral scotoma early due to the action on the papillo-
macular bundle.
Later the field undergoes great concentric and
irregular narrowing but following no definite
rule. Treatment may be divided into active and
prophylactic, active treatment to be of service
must be started early.
The unfortunate part of instituting treatment is
in the fact that it is only when the central ner-
vous system becomes involved and the poison hab
left the alimentary tract that the gastrointestinal
symptoms come on. Gastric lavage continued
for days, sweats, either turkish baths or pilocar-
pin, venesection, alkalies to counteract the acid-
osis and in severe cases lumbar puncture.
All these must be instituted early and pushed
to the point of tolerance. When the late atrophy
begins, no amount of treatment is of avail.
Prophylactic Treatment — The education of the
public that all raw liquor is exceedingly toxic and
that destructive symptoms are rapidly developed ;
that illicit liquor is as apt as not to be made from
alcohol denatured with 2 per cent methyl spirits
and that the dealer does not guarantee the purity
of his product.
Much valuable work in publicity and education
of the public has been done by the Committee for
the Prevention of Blindness.
In my opinion, this, like all other problems,
tends to solve its self. The fad of home brewing
and manufacture of illicit liquor is becoming each
day more difficult.
The old boys who will have alcohol even if it be
denatured, slowdy but surely, pass on and the new
generation coming will lack the general craving
for alcoholic stimulation.
I deem it our duty as physicians and occulists
to educate as far as possible, those with whom we
come in contact as to the deleterious effects, and
the great hazard associated with the consumption
of illicit liquor.
IXDIC.VTIOXS FOR UROLOGICAL
EXAMINATION*
Raymond L. Latchem, S.B., M.D., M.S.,
(Urology), Siou.x City,
Crologist, St. Joseph’s and German Lutheran Hospitals,
Sioux City, Iowa
Some indications for urological investigation
are generally recognized by the profession at large
and lead either to a correct diagnosis or to refer-
ence of the case to one trained in urological diag-
nosis. Cases with one or more symptoms such as
hematuria, pyuria, difficulty or frequency of ur-
ination, etc., comprise the largest part of the re-
ferred cases of the urologist who is not directly
associated in practice with a group of physicians.
Such cases include approximately but one-third
of the urological field. Braasch recently stated
“approximately one of every ten patients who
registered at the Mayo Clinic submitted to cysto-
scopic examination and 5 per cent, of all the sur-
gical cases were operated upon for lesions of the
urinary tract. The majority of these patients,
previous to examination at the clinic, had diag-
noses of lesions other than those of the urinar}’
tract and a surprisingly small number of the
cases with lesions of the urinary tract had had
correct diagnoses prior to their arival at the
clinic.” A similar statement is also reported from
the Montreal General Hospital. This condition
is probable true of other closelv allied or group
organizations. It is obvious from this that a
urological study is warranted in a greater percent-
age of cases than is usually recognized, and that
a consideration of what may be considered condi-
tions indicating urological investigation should
be profitable.
It should be remembered that a urological in-
vestigation of a case may be a simple or complex
precedure according to the difficulties of making
the diagnosis. It may vary from the simpler pro-
cedures such as urine examination, estimation of
renal function by the phthalien test, and determin-
ation of amount of residual urine, to complete
roentgenographic studies, cystoscopy, differential
studies of renal function, pyelography, etc. The
extent of the examination and the type of diag-
nostic procedures employed will vary greatly ac-
cording to the nature of the case and will at
times require considerable judgment both as to
the propriety of the procedure and as to the re-
sults obtained.
The indications for urological investigation may
be summarized briefly but comprehensively as
follows :
•Presented before the Medical Staff of the Sioux City Welfare
Bureau, regular monthly meeting. May 17, 1922.
450
Journal of Iowa State Medical Society
[November, 1922
1. Conditions frankly indicating urological le-
sions, pyuria, dysuria, difficult or frequent urination,
etc.
2. Roentgenographic shadows suggestive of loca--
tion in urinary tract.
3. History- of previous pyuria, hematuria, or
definite urological symptoms even in the presence of
negative urinary findings.
4. Tumors of the supra-pubic and upper lateral
abdominal area.
,s. History of abdominal pain without definite evi-
dence of disease in the intra-abdominal organs.
The order as given represents the frequencv
with which they are recognized as indications for
urological investigation. Group one furnishes the
largest majority of correct diagnoses or cases re-
ferred for examination. However, even* in the
group with frank urological symptoms, most of
which have serious importance, the necessity of
an exact diagnosis is not at times realized. Ks-
jtecially is this apt to be true in cases marked
solely by hematuria as this may be of short dur-
ation and painless, so that when the urine is again
clear a feeling of false security is created. The
other symptoms of the group having less tendency
to remission and often occurring together are
more insistent of attention and receive more con-
sideration than their silent companion.
The increasing use of the x-ray in diagnosis of
abdominal pain has made more familiar the fre-
quency shadow's in the area of the urinarv tract.
Probably about 50 per cent of all such shadows in
the renal areas are actually included in the kid-
ney and, of these .so included, only a small per-
centage are definitely recognizable as renal calculi
from study of the plate alone. This accounts for
the roentgenographic diagnosis of “doubtful or
questionable shadows” in the renal or ureteral
area. The identification or exclusion and locali-
zation of the shadow should be made by the
urologist. Clinical history may either be mislead-
ing in these cases or admit of the making of a
correct diagnosis, but the value of ureteral cathe-
terization, with the resultant knowledge gained by
differential functional tests of the kidneys, and
hy pyelography cannot be over-estimated.
The obtaining a history of previous urological
symptoms such as hematuria and pyuria, espec-
ially if attended bv bladder svmptoms, is always
worth investigating even in the presence, at the
time, of a negative physical and urinary examin-
ation. If investigated these cases will vield an
interesting variety of bladder and kidney tumors
or closed pyonephrosis and other conditions.
Tumors of the supra-pubic and especially of
the u])per lateral abdominal areasy are commonly
seen without clinical data suffic^nt to make a
positive diagnosis. It is in this group of cases
that the definite inclusion or exclusion of the
tumors in the urinary tract from data obtained
by cystoscopic examination becomes of the great-
est aid to the diagnostician and surgeon. It is
here that the negative urological examination,
while always \aluable in any case that seemed
worthy of investigation, has its greatest justifica-
tion.
Abdominal pain arising from the upper urinary
system is frequently met with and, in the absence
of pathological urinary findings, mav cause em-
barrassment to the diagnostician. The anterior
radiation of pain from retroperitoneal organs may
closely simulate the pain that may come from ap-
jiendicial or gall-bladder pathology', and in itself
is an untrustworthy guide to correct diagnosis.
The routine use of the roentgen-ray with the dis-
covery of shadows in the urinary area calls at-
tention to the urinary tract in a number of these
cases, but fails to give assistance in others. Hy-
dronephrosis with uninfected urine is the best ex-
ample of the combination of abdominal pain,
negative x-ray, and negative urinary findings that
often leads to the incorrect diagnosis of an intra-
abdominal lesion. A large majority of patients
presenting themselves with a right hydronephrosis
have previously been subjected to an abdominal
operation, usually appendectomy, without relief
of their complaint. Likewise, many^ cases of py-
elonephritis are missed because of the failure of
the examining physician to secure a microscopical
examination of the urine ( catheterized in the fe
male), or to consider the importance of either the
presence of but a few pus or blood cells in the
urine or a jirevious urinary history.
A more general knowledge of the above indica-
tions for urological investigation should lead to a
higher jiercentage of correct diagnoses in the
community. A closer study of slight or inde-
terminate symptoms in urology, as in other lines,
will lead to important diagnoses, and certainly
will diminish the number of cases eventually to be
recognized as urological because of the marked
renal insufficiency that has developed. .Serious
renal and bladder conditions may develop to a
marked or irremediable degree with only slight
symptoms to call attention to their presence. It is
not unusual to see a high grade renal insufficiency
present in cases of [welonephritis, and in bladder
retention due to prostatic enlargement of cord le-
sions. Many of these have developed insidiously
and without marked symptoms but more often
the fault has been that slight deviations from nor-
mal were neither appreciated nor investigated.
It is true that following up these indications
Voi.. XII, Xo. Ill
Journal of Iowa State Medical Society
451
will be attended with a larj:;e percentage of neg-
ative examination but this cannot be considered a
serious objection. Cystoscopy in trained hands is
a safe ])rocedure, and, while perhaps an uncom-
fortable e.x])crience, can be rendered painless,
even in the presence of pathology, by use of local
and caudal anesthesis. The extent of the exam-
ination and of the use of the axiliary aids such as
pyelography must be determined by the urologist.
RKKERE-NCKS:
I’raasch. W. I'.: Kelation of Urology to (iroiip ^Medicine.
Tour, of Urol. vol. vi, Xo. 4, Oct., 1021.
•10?' Trimble Hldg.
\DKNOIDS -\XD EYI-: STR.YIX IN
SCHOOL CHILDREN— WHY MANY
LEAVE SCHOOL
Percy R. Wood, M.D., Waterloo
-\denoids and eye strain .symptoms in school
children vary greatly in clinical manifestations
and in pathogenizing tendencies at different ])e-
riods and at different stages. Many of the worst
forms are not easily apprehended and so remain
unsuspected and permanently neglected. School
authorities, as sponsors for the physical fitness of
school children should leave no stone unturned to
guarantee them every possible physical advantage,
but certain precautions are necessary if this re-
sult eventuates. These defects if not discovered
and corrected during school days, not infrequently
cause the children to break in health, become dis-
couraged and leave school, only to learn later,
when the damage has become irreparable that it
could easily have been averted, had it received
proper consideration during school days. If
school children of all ages were examined every
three or six months in a well equijiped office,
and by a skilled medical man with jilenty of time
and adequate appreciation of the bearing these
abnormalities have upon their future, it would
conserve energy, health and future usefulness.
Otherwise, the cursory school room examinations
pass great numbers as normal, though seriously
afflicted. The most pernicious class of adenoids
are not the large ones that obstruct and cause
mouth breathing, arre.sted development, or mal-
nutrition, and which any novice may detect, but
the small sclerosed growths that fill the bursa and
Rosen Muellers Fossae or cling in strands to the
lips of the Eustachian orifices and other points in
the pharyngeal vault, in conjunction with hyper-
tro])hied membranes lining the nasal passages, the
vault and the Eu.stachian tubes.
These produce a most profound influence over
the function of hearing, ami are iiernicious.
chiefly because neglected. They consist of rem-
nants of either an im])erfectly operated adenoid
or an inconi])letely atrophied Euschka’s tonsil.
The author recalls hearing Prof. .\dam Politizer
frequently admonish his students to never neglect
examination of the nose and throat when diag-
nosing ear disea.ses.
d'he above described type present the most com-
mon etiologic factor in the production of catar-
rhal deafness in children and young adults. .\m-
])le authority e.xists for the statement that the ma-
jority of those seeking relief in late life from
progressing deafness, [iresent this condition, as a
mute evidence of neglect in childhood days. Such
cases should be ojierated u])on before instituting
ear treatment, at whatever age, if permanent re-
sults are to be secured.
Likewi.se the eye.s — it’s not how much one sees,
but how. If, in order to secure normal distant vi-
sion, the subject must employ the intrinsic ocular
muscles, a resulting eye strain ensues. Slight
errors of refraction exert a more pernicious and
pronounced influence over the general nervous
.system than do larger ones, since these contin-
uously and unremittingly overwork the cilliary
muscles. Visual acuity being good, these defects
are not easily detected, or even surmised, and re-
quire skill, experience, and fine technique to dis-
cover. Moreover these call forth innumerable
forms of neuroses, ranging from indigestion, con-
stipation and general nervousness to chorea, noc-
turnal enureses, melancholia, mental instability,
hysteria and insanity. Thus forcing many from
school into menial occupations or criminal and
vagabond lives. This class of cases are more
common than those with larger and more easily
discerned refractive errors, but are less fre-
quently detected. These later afford poor vision
but good health, and cause little or no pain or
distress, referable to the eye, and which anyone
without medical training may diagnose, but slight
errors though inversely profound in their influ-
ence over the general nervous system are not to
be detected without employment of a mydriatic in
conjunction with delicate instruments in the hands
of those e.xperienced and skillful. These young
people see much, though not well, experiencing
few symptoms distinctly referable to the eye it-
self, but suffering systemic disturbances of a
much wider scope and of a far more ominous
significance. The origin of which, not infre-
quently, neither patient nor family physician di-
vines, since their sight has caused them to be
passed as visually normal. These matters are of
grave consequence to public welfare and should
not be relegated to the care of those imi)re])ared
452
Journal of Iowa State Medical Society
[November, 1922
by education or training to appreciate the situa-
tion, or do it justice. The asylums and lower
walks of life are filled with practical evidences
of these facts, and herein lies the tragedy.
School children should be frequently examined
for adenoids and eye strain, and by an experienced
man with adequate equipment. Since eyes change
often in the young and adenoids are frequently
unsuspected, the most pernicious class from the
viewpoint of the child’s future escape detection
because the examiner lacks experience, ability,
time and means for making a thorough and prac-
tical medical examination.
Summary
-Adenoids that pass unnoticed are not the large
obstructive ones which any novice may discover,
but the submerged and sclerosed growths which
do not obstruct : do not cause mouth breathing,
nasal stenosis or restricted development. These
are more commonly found in children ranging
from ten to fifteen years of age and upward and
the older the more profound their influence over
hearing.
They consist of strands and tufts of sclerosed
lymphoid tissue attached to the Eustachian ori-
fices and other points in the vault and extending
even into the tubes in conjunction with hyper-
trophied and hyperemic vault membranes com-
posed of remnants of either imperfectly atro-
phied or imperfectly operated adenoids. Authors
agree that 85 per cent of ear diseases have their
origin in the vault due to conditions as herein de-
scribed.
This type constitutes the most common and
fruitful etiologic factor in the production of de-
fective hearing in young adults and those of mid-
dle and old age. Therefore it is an injustice to
the child to be led to believe itself normal in these
regards and to later discover the damage irre-
parable.
The author in conjunction with many promi-
nent in this line of work, finds these conditions in
the majority of those who later in life apply for
relief from progressing deafness. These should
be operated upon before instituting treatment for
catarrhal deafness, even at the ages of sixty and
seventy years.
STATE MEDICAL LIBRARY
About 130 new books hav'e recently been added to
the library. Miss Van Zandt, the librarian, expresses
herself much pleased at the interest manifested by
the profession of Iowa in reference to books and
journals.
TESTIMONIAL DINNER FOR DR. JAMES
TAGGART PRIESTLEY
One of the pleasant incidents connected with
the first annual clinic of the Polk County Med-
ical Society was a testimonial dinner given by
the county society to Dr. James Taggart
Priestley, at the Hotel Fort Des Moines, on
October 18, 1922, in recognition of his faithful
and distinguished services as a practitioner of
medicine.
Doctor Priestley graduated in the medical
class of 1872 of the University of Pennsylvania,
so that he has completed a half century of
medical practice, and all but one year of this
period was spent in Des Moines.
Dr. A. P. Stoner, president of the Polk
County Medical Society, acted as toastmaster
in a most gracious and pleasing manner.
The toast “Doctor Priestley the Physician ’
was responded to by Dr. Charles Lyman
Greene of St. Paul, and it will be of interest to
give an outline of his toast.
Dr. Charles I.yman Greene, St. Paul ;
PRIESTLEY, THE PHYSICIAN
Mr. President, Ladies and Gentlemen;
Not long since curiosity moved me to seek in
“Webster” the definition of “middle-age.” To my
amazement I found that the term covered that period
lying between the ages of thirty and fifty — youth
had flown — middle-age had passed and all unwit-
tingly, and without a pang, I had achieved the thresh-
hold of “old age.”
This state is understood to carry an obligation to
accept it gracefully and a boon in the form of un-
limited retrospection. The latter will be exercised
freely tonight, as affording the best means of at-
taining an understanding of some of the elements
entering into the building of the character of that
great and good man whom we all love and honor.
Born in 1852 and entering upon the practice of
medicine twenty years later. Doctor Priestley has
enjoyed the privilege of seeing such stupendous
growth, progress and achievement in his chosen
profession as no sane mind of a previous generation
could have conceived, or even envisioned in a dream.
The year of his graduation 1872, was little more
than two decades removed from the date of the in-
troduction of ether and chloroform. The surgeons
of his day no longer operated (deftly and with fever-
ish haste) upon terror-stricken, cruelly agonized,
shrieking and imploring victims, bound to the oper-
ating table or forcibly held down by assistants, but
nevertheless, the miracle or induced painless slum-
ber had not widened greatly the surgical field nor
saved the patients from septic poisoning.
Pus abounded, erysipelas stalked ever abroad and
slew annually its tens of thousands — while gangrene
all too frequently, made the hospital wards a place
VoL. XII, No. 11]
Journal of Iowa State Medical Society
453
of horror and a stench to the nostrils. In the case of
major operations, only the lucky survived. Even in
the late eighties 1 heard the learned and skillful
professor of surgery in one of America’s greatest
medical schools discourse learnedly upon the vir-
tues of the then inevitable “laudable” pus and the
unfortunate characteristics of the “damnable” va-
riety.
Incidentally he furiously abused Lister and all his
words. Yes, vilified and help up to scorn that lion
hearted, gentle and infinitely modest man who even
then had brought to mankind such a gift of healing
as no other perhaps ever has bestowed.
Going to London in 1890 after my graduation, I
walked the wards with that great investigator and
discoverer, my father’s very dear friend, and saw the
magical workings of his primitive carbolic spray —
associated with what I recognized with astonished
amusement as a somewhat imperfect adherence to
the strict canons governing surgical cleanliness al-
ready established and taught by the best of his di-
ciples in our own country.
In certain other great London hospitals one even
then shrank appalled at the operative slovenliness
of men whose names he had been taught to revere.
For these, the abdominal cavity, the joints and the
brain should have been forbidden territory still —
for such as these the compound fracture still spelled
death to the victim.
In their wards, gangrene, septicemia and pyemia
abounded. In those of Lister they were but hateful
memories.
Medicine in the early seventies was affording only
faint glimmerings of promise for the future. Malaria
was still “marsh miasm” a thing of mystery, its
cause and prevention unknown. Typhoid fever, its
etiology unknown, and but newly differentiated from
typhus by Louis, was killing its hosts without let or
hindrance. Neither the prevention nor even the
diagnosis of tuberculosis had passed the rudimentary
stage of development, and the results of treatment
were almost nil. The presence of lues venerea was
suspected only when active and out-spoken symp-
toms were present.
The “black-death” still a thing of mystery, slew its
hundreds of thousands in epidemic waves sweeping
at will, unhampered and unchecked from time to
time over the Orient, Japan and the Philippines, now
happily almost free from its ravages. Yellow fever
and .Asiatic cholera frequently visited our shores and
left behind a ghastly army of the dead. Indeed,
Asiatic cholera was with us in the year of Doctor
Priestley's birth and in those represented by his
sixteenth and seventeenth birthdays.
Many of the medical men here present remember
the horrors of diphtheria in those pre-antitoxin days.
The dreadful feeling of helplessness and futility that
possessed us — our unavailing efforts to save little
children, dying agonizing deaths, from the disease of
which we knew next to nothing. An enormous death
rate from puerperal fever was another of the trag-
edies of this period and what could be sadder, more
pathetic, more heartbreaking, than the passing of the
beloved wife and mother in the act and bringing her
child into the world. A reading of the family records
of those days makes clear the significance of the
special prayer for “women in the perils of child-
birth.”
But why extend the list? Our knowledge of dis-
ease lacked then the one prime requisite to accurate
diagnosis and treatment — namely, a knowledge of its
cause. The rapidity of our advance in fifty years is
little appreciated by the younger generation of
medical men.
Every student and more recent graduate should
pick up somewhere a volume on medicine or sur-
gery published in the late sixties or early seventies
and after perusing it give thanks to God for the
greater opportunities that he has enjoyed. Let him
consider prayerfully and thankfully also the fact that
in those days hospitals were few, unsanitary, and
miserably equipped, and any general diffusion of
properly trained nurses wholly lacking.
Any adequate knowledge of “public health” was
not then to be had even by the physician and such
truths as he had learned were in the main impossible
of application by reason of a hostile public opinion
born of the greater ignorance of the laity.
Quacks flourished and abounded to an 'extent un-
known today and the nostrum venders plied their
lucrative trade and preyed upon a gullible public
without let of hindrance — free to advertize any
claims, however false, and to include in their precious
mixtures any sort of habit-firming drug.
In 1872, medical education had advanced but little
and the best of our teaching institutions gave their
instruction almost wholly through didactic lectures
of the flamboyant, oratorical and declamatory type.
Such bedside teaching of groups and individuals as
now exists was practically unknown. Laboratories
were crude and laboratory methods sketchy and in-
effective. Even in the late eighties it was difficult
to find a decently conducted course, even in applied
physiological chemistry.
The promise of a great dawn to come even then
was reflected from only a few of the highest peaks.
Entrance requirements were ludicrous in their sim-
plicity and for the most part, purely a matter of
form. The desire to be a physician was about the
only prerequisite to admission. Even in my later
day, the students of medicine and law were looked
upon as a “race apart” by academic students and
professors and, by college landladies, as “parties” to
be given food and shelter only when need pressed
and even then with doubts and forbodings too often
well founded. Indeed, this attitude in the main was
justified, yet both groups abounded in sincere and
earne.st men— men of ability, of force and of de-
termination.
Most of them had worked hard and sacrificed
greatly to get to college and brought with them
high ambition and a fine loyalty to their future pro-
454
Journal of Iowa State Medical Society
[November, 1922
fession. Nearly all who could stay on and pay thcii
way by work or money were graduated after a short
course, and once off the campus, could practice
where they liked, for state examining boards were
then unknown.
Each and everyone of these must have gained his
knowledge of actual practice by using his early pa-
tients as his individual material for hazardous clin-
ical experiments had it not been for the old time
S3Stem of “preceptorship.” .\11 students were sup-
posed to be under the guidance of some active prac-
titioner of medicine, and upon his ability, interest and
teaching efficiency, depended in large measure the
practical attainments of the disciple at the time that
he was turned loose by his medical school upon an
innocent and unsuspecting world. The old sv'stem
in this one respect was admirable, and many a prac-
titioner still living thinks with grateful appreciation
and sincere affection of the busj' man who gave him
more than his school could give and instilled the
highest concepts and noblest precepts of that pro-
fession which we all love and honor.
Have I drawn too gloomy a picture of the early
seventies? Yes, for although, judged by the vast
sum of accumulated exact knowledge that w'e now
possess, the ignorance of that time seems appalling.
It is true, nevertheless, that a great amount of useful
knowledge had been accumulated and beautifulh'
formulated and, furthermore, that fact after fact of
great importance was being added almost daily.
All over the world enthusiastic investigators were
seeking and establishing new truths — isolated pri-
marily, perhaps, but destined oftentimes w'hen set
in its proper relationship to other truths to form a
link in the chain leading to some revolutionary dis-
cover\^ The physician knew much of drugs and
their action, and a vast amount about symptoms.
The art of physical diagnosis was developing, the
stethoscope had come gradually into its own, a con-
siderable amount of physiology was crudeh' taught,
pathologv’ had its beginnings, and the surgeons of
that day whether clean or dirty, w'ere splendidly
swift, fearless operators and knew their gross an-
atomy.
Furthermore, man\- of the medical men of Dr.
Priestley’s earlv' ^ears of practice, though lacking
most of the diagnostic aids now available, were
within their limited field, truh' remarkable diagnos-
ticians and clear and convincing teachers. They were
keen observers and made their special senses serve
them better perhaps than does the present more
modern and more highly endowed generation. It
was felt that great progress — a vast fund of new
knowledge lay in the near future — almost wdthin
grasp, and at no time did there exist a more eager
and receptive body of medical men.
When one considers these conditions present in
1872 he must indeed realize that in medicine and sur-
gery alike it was a day of “shining lights.” Special
ability and aptitude, whether combined with, or lack-
ing, opportunities above those of the mass, tended to
throw certain commanding figures into strong relief.
Indeed the presence of great numbers of utterly
wretched and worthless medical schools, the lack of
proper requirements for entrance and for graduation
alike in all resulted in a low average of attainment
and made such commanding figures giants indeed.
When, in 1874 your beloved physician came to the
little far-western town of Des Moines from the con-
servative and prim atmosphere of Northumberland,
Pennsj'lvania, he brought with him not onlj' those
attributes which made for medical distinction, but
certain others which all too many of the giants of
those days lacked.
Like them he loved his profession. He gloried in
its past achievements and was full of faith for its
future. Ever alert, he never allowed the great wave
of scientific progress to engulf him but rode upon its
crest, an earnest tireless student, during every year
of his half century as a physician. He was imbued
with the spirit of service and filled with the desire
to carr\- health and healing with him wherever and
whenever opportunity called.
He was ready to give his best to sick and poor
alike and to hazard health and even life daily in the
course of duty. The spirit of mercy abounded in him
and he gloried in good deeds modestly and quietly
achieved.
Guiding and inspiring him in his professional work
was a code of ethics, tinctured with imperfections
born of the stress of the times, much abused then,
as in later years, by those unworthy ones whom it
harassed and stung, but one, nevertheless, which em-
bodied the very soul of altruism, good works and
just dealing.
It would appear that Doctor Priestley made his
strong impress upon his communitj’ early and that
it deepened with the passing years.
It is obvious also that he won quickh' the respect
and affection of his medical colleagues and ever has
stood for high ideals, harmony and progress in the
profession of the state.
To serve was his aim — to advance his profession
one of the impelling desires of his life, and his
achievements in the betterment of medicine have
been evidenced not onl\' within his own cit\' and
state, but nationally as well.
He is possessed of breadth of view and openness
of mind, is an invincible optimist, a man of high
resolution, resourceful, fearless and determined, hon-
est, upright, steadfast, wise and just.
But what are those added qualities which have so
endeared him to his townsmen and his fellows in the
medical profession — what attributes have made him
the beloved physician to be honored and feted with-
out stint by laymen and physicians alike upon the
completion of a half century of service’
They are such as would further ennoble what
would otherwise be the filthiest and most ignoble of
callings — plus certain more intimate personal gifts
that lend themselves less readiU' to description. \\ e
know that no man can win such affection unless he
Voi.. XII, Xo. Ill
Journal of Iowa State Medical Society
455
is unselfish, ever helpful, and full of love for his
fellowman. To hold such love in his heart, he must
have achieved a keen sense of humor, a broadminded
tolerance, charity, a deep understanding of human
nature, a broad humanity and a noble generosity in
thought and deed.
If to these rare attributes we add the qualities of
modesty, gentleness, tenderness and understanding
sympathy and to these again that mysterious “gift
of the Gods’’ which we term “personal charm” and
recognize as the true reflection of sweetness of soul,
we may better understand why Dr. James Taggart
Priestley has become to his medical colleagues and
to his people not only “the beloved physician,” but
guide, counsellor, and friend.
Doctor Priestley, I congratulate you upon having
so happily attained the age of three score and ten —
upon your good work and great achievements in and
for the profession of medicine. I felicitate you upon
carrying into a well earned and honored retirement
the abounding love and gratitude of your people, and,
with all honor and respect to that great discoverer,
your illustrious ancestor, Doctor Joseph Priestley, I
can not hold yours the lesser achievement.
The toast “Doctor Priestley, His Relation to
our Medical Society” was responded to by Dr.
P. Stoner the president, and he referred
particularly to Doctor Priestley’s long and
faithful services in developing the County Med-
ical Society, his great influence in elevating
professional ideals, and promoting the best of
relations with the younger men of the society.
In conclusion he presented to Doctor Priestley
a silver loving cup as a tribute of affection on
behalf of the Polk County ^Medical Society.
In response. Doctor Priestley spoke as fol-
lows :
It is a rather novel sensation to attend one's own
wake.
I fully realize the truth of the opening stanza of
that matchless rimester’s (Byron) “Inscription on
the Monument of a Newfoundland Dog.”
“When some proud son of man returns to earth,
Unknown to glory, but upheld by birth.
The sculptor's art exhausts the pomp of woe,
-•\nd storied urns record who rests below;
When all is done, then upon the tomb is seen.
Not what he was, but what he should have been.’'
There is no man so devoid of Ego that he would
not be deeply impressed by this extraordinary ex-
pression of friendship and esteem.
half century among you has given ample oppor-
tunity for my faults to become known, and one’s
escapades are generally well remembered, and fre-
quently mentioned. You certainly have had in mind
that charitable motto of the Elks:
“The faults of our friends we write upon the sands
— their virtues we inscribe upon the tablets of love
and memory.” Or that true test of a wife’s love —
to know the faults of her husband, and to overlook
them.
.■\n old man’s stories generally begin with “1,” and
end with “me.” Garrulousness is a pronounced symp-
tom of senility, although the most marked symptom
is the inability to recognize one’s own senility. Bear-
ing this fact in mind, 1 shall try to avoid being te-
dious, stimulated by an incident that occurred during
my early youth. \ dearly beloved old Scotch Pres-
b\-terian clergymen, who was my tutor for many
years, and perhaps may be responsible for what, in
these \’olstedian days, is considered an unpardon
able sin, was my companion on a tour over his na
tive heaths, in Scotland. 1 had to awaken him fre-
quently from his slumbers, while on his knees at the
bedside, and lift him into his bed, after a strenuous
day of ministerial work. His ejaculatory expletives,
while I was so engaged, sounded remarkably like a
continuation of his prayer, R. I. P. Once, while he
was preaching in the little old school Presbyterian
church of my native town, the long-winded second
prayer had been finished, and the elders were passing
the plates for the financial contributions, when a
thrifty old parishioner arose and was trying to make
his exit unnoticed. The preacher spied him, how-
ever, and spoke in a stentorian voice, “Some men
have no charity,” and the old parishioner turned
and answered, “Na, na, it is not that at all, but ye are
so teajous.”
When I had my first introduction to Des Moines
the population was 12,000. The old capitol stood
south of the present one, a small brick building, and
there were two bridges across the Des Moines river.
These were both toll bridges, and the toll to. cross
either of them was ten cents a huge sum in those
days. Fortunately, the river was fordable, and you
may be sure that I forded the river whenever it was
possible to do so. A street car ran from the west
end of Court avenue, at the court house, to East
Seventh and Court. It was built by a pioneer M.D.,
and the motive power was “Maud,” assisted in the
muddy season by the pushing power” of the kind,
lovable old doctor.
The medical profession was represented by sev-
eral excellent men, some of them of a brainy type.
.-Ml have gone except that old Nestor, Dr. Field,
even then using his microscope in microphotography.
Many of us had the opportunity, within a few years
past, to see what remarkable work he did in the
early seventies. My admiration for him was bound-
less, for, when I was a student at the University of
Pennsylvania in 1872, we had but one microscope for
a class of five hundred. To look into it was the am-
bition of every student in the class, and when the
learned professor focussed it on some tube casts, and
invited the class to come to see them, the onrush
was so great that the tube casts and microscope, to-
gether, were on the floor before one student had had
an opportunity to take a look. By persuasion, I in-
duced my grandmother to buy me a microscope, a
“Queen,’’ and then there were a “pair of queens,” mv
456
Journal of Iowa State Medical Society
grandmother and the scope. This was her gradua-
tion present to me.
The great Rawson was one of the leading men at
that time — he gave me my first lesson in thrift. I
was assisting him in an operation, in w'hich the
sutures were silver wire. As he cut the ends of
these silver sutures, the small pieces which remained
were carefully laid aside. Curiosity compelled me
to ask him why he hoarded these so carefully, and he
replied that he sold them to the silversmith. The
Rawson block at Eighth and Locust, and a handsome
fortune besides, was the reward for his thrift and
capability.
Dr. Hanawalt was the best railroad surgeon that
I ever knew, beloved by all his clientele, and saved
more badly injured hands and feet than I imagined
could be possible.
Then came Dr. Smouse, w'ho learned all of his sur-
gery by working it out on his patient, and soon be-
came one of the most brilliant surgeons in the state.
He retired too early for his own happiness and the
good of humanity.
Soon after came Schooler, one of the best minds
we ever had in the profession, and were it not for
presbyacusia, would be enjoying this reministic talk
of mine. The spirited controv^ersies between him and
his wonderfully brilliant confrere Woods Hutchin-
son, which occurred every night that the Polk County
Medical Society met, in some physician’s office, or
•in the room of the “Overseers of the Poor” (a touch-
ing heart to heart coincidence to most of us) at the
court house, were as entertaining as the most bloody
bull-fight in the bull-ring at Madrid.
As the cit\' grew, the profession grew with it.
One of the most pleasing remembrances of my life
is a letter that Dr. Page wrote to me when he re-
moved from the East Side, in which he made refer-
ence to the fact that in all our years of competitive
practice on that side of the river, there had never
been an unkind word between us, or an unpleasant
incident of any kind. A most accomplished, kindly
man, always a gentleman, and a worthy sire to a
worthy, accomplished son, our present Dr. Page.
One of the most active workers in the Society in
those early days was our friend Doctor Cokenower,
and who has ever since kept up his active interest
in both county and state society affairs. Dr. A. M.
Linn was the first homeopathic physician of promi-
nence to come to Des Moines, and he is now asso-
ciated with us in all our best endeavors. The lovable
Patchen had a charm that will always be remem-
bered. ^lanj- will remember the brilliant Dr. Swift,
who tarried with us for a w'hile, then left us for a
practice in Connecticut, where I believe he is still at
work. In the later development of our medical
school we welcomed the great surgeon. Doctor Fair-
child, who stimulated the best of medical work, and
is now the capable editor of our State Journal. In
more recent years our beloved Bierring came to live
among us, and we have all taken a personal pride in
the honor that was extended to him during the past
[November, 1922
year by the Royal College of Physicians of Edin-
burgh.
The hospitals came, at first, primitive, but now the
peers of those in any city of our size in the country.
Five large hospitals, all standardized, thanks to Al-
lah and the unfailing efforts of that tireless worker,
who often had to use the big stick, the brainy and
brilliant Pearson.
Our old friend. Dr. Amos, who gave so many j-ears
of tireless service to his many patients, has returned
to the city, to be with us again.
It is impossible to mention all of the scholarly,
resourceful men who at present represent the med-
ical profession in our city. I want to thank you one
and all for the kindly fellowship that you have ex-
tended to me, and I know that there is not one of
you that I could not grasp by the hand and call a
friend.
Like unto Solomon, who, in all his glory, sur-
rounded by all his people, the beasts of the field, and
the fowls of the air, was offered a cup filled with the
water of eternal life. He asked, “Is there water
enough for my friends?” and the angel said, “No,
only enough for you alone.” He still hesitated as to
whether he should partake of the draught, when
Boutimar, the wild dove, the most loving of all birds
said, speaking in the tongue of birds, known to Solo-
mon only among mortals, “Oh, Prophet of God,
how couldst thou desire to be living alone, when each
of thy friends, and of thy counsellors, and of thy
children, and of thy servants, and all those who love
three, are counted among the dead? For all of these
must surely drink of the bitter waters of death,
though thou shouldst drink the waters of life.
Wherefore desire everlasting youth, when the face
of the world itself shall be wrinkled with age, and
the eyes of the stars shall be clouded by the black
fingers of Azrael? When the love that thou sung
of has passed awa\' like the smoke of frankincense,
when the dust of the heart that beats against thine
own shall have long been scattered by the four
winds of heaven, when the eyes that look for thy
coming shall have become a memory, when the
voices grateful to thine ear shall have been eter-
nally stilled, when thy life shall be one oasis in a
universal waste of death, and thine eternal existence
but an eternal recognition of eternal absence —
will thou indeed care to live, though the wild dove
perishes when his mate cometh not?” And Solomon,
without reply, silently gave back the cup filled with
the water of eternal life. But upon the prophet
king’s beard, besprinkled with powder of gold, there
appeared another glitter of as clear dew, the diamond
dew of the heart, which is tears.
Again I want to thank you all for the great pleas-
ure you have brought into my life, and particularly
you. Dr. McCarthy, my dear foster son, who came
into my life and have so wonderfully filled the aching
void in my heart, caused by the loss of your com-
panion, mv own brainy, brilliant, beloved doctor son.
Thank you.
457
VoL. XII, No. 11] Journal of Iowa State Medical Society
PHYSICIANS ACTIVE IN PUBLIC HEALTH
WORK
Field Activities Committee of State Medical Society
in Cooperation with other Organizations —
County Medical Societies to Boost Christmas
Seal Campaign
W. L. Bierring, M.U.
A short time ago the work and purposes of the
Field Activities Committee of the Iowa State Med-
ical Society and its new director. Doctor F. E. Samp-
son, formerly of Creston now of Des Moines, were
introduced by Doctor Walter L. Bierring, chairman
of the committee, in a letter to county medical so-
cieties. Shortly following that the Sunday Register
and Tribune carried on the first page a copy of this
letter and a long article relating to Doctor Sampson’s
work under a double column heading. This was an
excellent piece of publicitj' and an old newspaper
man remarked that it was the best advertising that
the medical profession has ever received in Iowa,
.^nd it was legitimate advertising too. Publicity of
this sort and many other services are being secured
through cooperation which is being established by
the Field Activities Committee with other state agen-
cies interested in public health, particularly the
Iowa Tuberculosis Association and the State Con-
ference of Social Work.
As a further instance of the value of such co-
operation Doctor Sampson is now on an extended
speaking tour throughout the state of which itiner-
ar}’ many of the dates have been made through local
public health associations consisting of laymen as
well as physicians. In communities where he has
been invited to speak to county medical societies the
local lay health groups on the suggestion of the
State Tuberculosis Association are arranging joint
meetings.
In. view of this movement to correlate the medical
profession with public health activities a description
of the Christmas seal campaign and its purposes will
be of interest.
On December 1, twenty-four million Christmas
seals will be placed on sale by health w'orkers
throughout every county in Iowa.
The proceeds are used locally for various forms of
public health promotion such as nursing, nutrition
classes, the modern health crusade and other health
work in the schools, tuberculosis and child welfare
clinics, open air schools, free dispensaries and perma-
nent clinics, milk lunches for school children, instruc-
tion for mothers in the care of babies, prenatal care,
fresh air camps, distribution of health literature, ex-
hibits and other means of health education.
A minor share goes to the State Tuberculosis As-
sociation, which uses it for the campaign against tu-
berculosis and for educational health work similar to
the local forms; and five cents on the dollar supports
the national anti-tuberculosis movement.
The design of the sticker is a radical departure
from those used in previous years. It is symbolical
of the present interest on the part of health workers
in the mother and child. It shows in the foreground
a mother holding a child, while in the background
is a Christmas tree lined against a sky whose hue
is the now fashionable periwinkle blue. Over the
center of the tree is the emblem of the world-wide
movement to eradicate tuberculosis, the bright red
double-barred cross. At the bottotii of the seal are
the words “for health.”
The seal was drawn by T. il. Cleland, a celebrated
artist, and was approved by a committee of national
FOR. H E ALTH
and state officials with the advice of Richard S. Back
of the Metropolitan Museum of Art and Heyworth
Campbell, art editor of the Nast Publications. The
Metropolitan Aluseum declares that the 1922 seal is
the best ever produced in the fifteen years history
of the National Tuberculosis Association.
The posters, designed by Ernest Hamlin Baker
and the Ethridge Association of artists, are also es-
pecially attractive. One will make a strong appeal
to school authorities and to school children, as it
shows a beautiful child standing at a blackboard
writing, “The good they do depends on you,” the
sentiment evidently referring to the seals which
decorate the Christmas packages lying at his feet.
This year’s campaign is based on hard facts — the
showing in dollars and cents of the measurable value
of public health work.
That every child born today may expect to live two
and one-half years longer than if born ten years ago
is a fact established by the records of the United
States Census Bureau’s department of vital statistics,
Every year the average span of human life is in-
creased.
In a bulletin aptly entitled “Lengthening Life,”
the Metropolitan Insurance Company shows how it
has added to the life expectancy of its insured white
males five years in the last decade and in the case of
white females four years. It attributes this result
to the public health work which it has done over this
period along three lines: education of its policy-
holders for disease prevention, teaching of health
habits to children, and public health nursing. It
458
Journal of Iowa State Medical Society [November, 192^
frankly admits that it has made money — getting more
premiums from live people and saving more princi-
pals of policies on those who would have been dead
than it spent for visiting nursing, distribution of
health literature and instruction in health habits of
children and adults.
It further asserts that the decrease in the general
death rate mentioned above is due primarily to the
work of health agencies, public and private.
Most striking of all, it continues, is the retreat of
the “White Plague.’’ Since the National Tuber-
culosis Association was founded in 1905, with the
State Associations later in quick succession, the tu-
berculosis death rate has declined from 201 per
100,000 to a life gain of 43 per cent.
Is disease prevention a good insurance policy?
Listen to the tale of two little cities in our neigh-
boring state of Illinois. In one there was spent for
health purposes in a year three cents per capita — in
the other eight cents for each person. In the former
the economic loss in the year from preventable com-
municable disease was $41.40 for every man, woman
and child — in the latter it was $17.45 per capita. The
second city spent five cents more and saved $23.95.
Is spending for community health wise statesman-
ship— and shrewd politics?
The children of the great open countr\' are not so
healthy as the children of the crowded cities, says
the Service Bulletin of the Extension Division of the
University of Iowa. It shows in graphic diagram
form that figures collected from nearly 3000 rural
and city schools reveal higher percentages of phy
sical defects among the rural school children ex-
amined than among the city school children.
Tuberculosis also is more prevalent among botli
children and adults in the countr}-.
Why is all this?
The cities spend twice as much from the public
treasury for public health. !Many city schools have
medical and dental inspection — open air rooms —
gymnasia — and organized recreation. Still more to
the point is the fact that voluntary agencies sup-
ported by private contributions do all sorts of public
work — maintain visiting nurses, school nurses, child
welfare nurses, tuberculosis nurses — establish free
dispensaries, and clinics both for diagnosis and treat-
ment— run fresh air summer camps — furnish milk
lunches to school children — and unceasingly" through
the spoken and printed word reiterate the gospel of
good health.
The city is organized for health — the country is
mostly unorganized — and it can be shown county by
county" that where there is an active county public
health association with a working program and some
even though scanty" funds to work with, health con-
ditions are better than in those counties where the
citizens have not banded together for their own wel-
fare and the health of their community.
Is building for the future health of the individual
a good investment i"
The Iowa Tuberculosis .Association has gathered
figures for the past three school years on 227,000
children examined for physical defects, with the fol-
lowing result:
Defects Year 1918-19
Teeth 60%
Tonsils and adenoids 55%
Underweight 60%
Vision 12%
Hearing 5%
Year 1920-21
39%
29%
32%
12 plus %
4%
These children attended schools where the Alod-
ern Health Crusade, a system of teaching healtli
habits, was used.
Does health education pay"?
This marvelously successful sixteen years’ drive
against tuberculosis has been supported entirely by
the sale of the Christmas seal. In the state of
Iowa the proceeds of seal sales are used for all forms
of public health work, with the stress upon child
health.
“Every seal you buy,” said a business man the
other day, “adds a definite fraction of time to the
span of human life.”
The Christmas seal is the symbol of a nation-wide
crusade against ill-health — it binds together quarter
section, village, city, state and nation in a construc-
tive common cause, that of all for health and health
for all.
Every seal with its gay" Christmas colors, adorning
a gift which the postman carries from friend to
friend, is a message of hope and health and a sign
that the sender has a care for the welfare of his
neighbors and his community.
Every seal on the back of an envelope helps stamp
out human ills.
The billion seals which health workers hope will
be bought — and used — this December will add “years
to life and life to the years we live.”
Des Moines, Iow"a, July 6, 1922.
Hon. N. E. Kendall,
Governor, State of Iowa, Des Moines, Iowa.
Iowa State Board of Health
Dear Sir:
I have the honor to submit the report of the Bu-
reau of \ enereal Disease Control for the vear ending
Tune 30, 1922.
The state appropriation for the year' was $25,000
and the e.xpenditures were as follows:
■Administration $ 5,323.06
Laboratory 8,006.70
Treatment 5,081.09
Education 6,589.15
Total $25,000
Fourteen clinics were maintained during the year
in the following cities: Des Aloines, Dubuque, Clin-
ton, Fort Dodge, Alason City, Grinnell, Sioux City
(2), Ottumwa, Council Bluffs, Marshalltown, Dav-
enport, Manly, Iowa City'; these were supported by
the local counties or cities, with the exception of the
clinic at Iowa City which is supported by the state;
the medication was furnished by this Bureau.
\'oL. XII, No. 11]
Journal of Iowa State Medical Society
459
On June 30, 1921, there remained under treatment
at the various clinics 508 cases; and during the year
new cases were admitted and treated, classified as
follows:
Syphilis Gonorrhea Chancroid
Male 408 430 22
Female 319 239
Total 727 669 22
The total number of consultations, treatments and
visits were 31,039. The total number of doses of
arsphenamine or neo-arsphenamine administered was
7761.
In addition to the work of the clinics, private or
city physicians administered free of charge 1406
doses of arsphenamine or neo-arsphenamine and 298
doses of mercury to indigent patients suffering with
venereal diseases, the medication being furnished by
this Bureau.
Through the activities of this Bureau, a large num-
ber of cases were sent to the State University Hos-
pital and were treated by Dr. N. G. Alcock.
There were 24,891 Wassermann tests made, of
which 4168 were positive, the balance being negative
or rejected. There were 2,209 gonorrheal tests made
of which 332 were positive.
Adair
49
Green
9
Adams
6
Grundv
7
38
Guthrie
1
Appanoose
124
Hamilton
24
.Audubon
7
Hancock
30
Benton
46
Hardin
51
Blackhawk
686
Harrison
9
Boone
150
Henry
60
Bremer
48
Howard
Buchanan
479
Humboldt
1
Buena Vista
72
Ida
35
Butler
104
Iowa
53
Calhoun
141
Tackson
51
Carroll -
189
Jasper
336
Cass
Jefferson
62
Cedar
, 18
Johnson
4797
Cerro Gordo.
236
Tones
90
Cherokee
430
Keokuk
17
Chickasaw
12
Kossuth
28
Clarke
53
Lee
1206
Clav
32
Linn
1227
Clavton
3
Louisa
15
Clinton
372
Lucas
17
Crawford
Lvon
27
Dallas -
.. 23
Madison
2
Davis
3
Alahaska
40
Decatur
25
Marion
277
Delaware
92
Alarshall
181
Des Aloines
..150
Mills
28
Dickinson
32
Mitchell
3
Dubuque
174
Monona
58
Emmet
33
Alonroe
102
Favette
..166
Montgomerv
25
Flovd
— 5i
Muscatine
213
Franklin
18
O’Brien
67
Fremont
Osceola
3
Page
301
Taylor
6
Palo .Alto
21
Union
40
Plymouth
74
Van Buren
♦
Pocahontas
55
Wapello
142
Polk
7307
Warren
*
Pottawattatnie
236
Washington
37
Poweshiek
94
Wayne ;...
14
Ringgold
*
Webster
355
Sac
10
Winnebago
5
Scott
786
Winneshiek
21
Shelby
70
Woodbury
1151
Sioux
19
Worth
23
Story
135
Wright
77
Tama 1 1
*Not utilizing laboratory.
The physicians of the state reported to the secre-
tary of the State Board of Health 926 cases of
syphilis, 2043 cases of gonorrhea and fifty-eight cases
of chancroid.
Dr. Jeannette F. Throckmorton gave 543 lectures
reaching 100,525 women and girls in 143 cities and
towns of the state, requiring 410 speaking hours.
Also by invitation of the president. Dr. Throckmor-
ton spent two days lecturing to the students of
Sioux Falls College, South Dakota. Lectures were
given to high school girls, college women and women
in industry and business.
The total number of pamphlets distributed in re-
sponse to requests from individuals, schools, lec-
turers and field workers was 27,543.
The venereal disease slides and charts were shown
twenty days during the months of .August and Sep-
tember at the state and county fairs. The total num-
ber viewing these exhibits w^as 100,000; and there
were 15,000 pamphlets distributed during these fairs.
There w'ere forty-three film showings made with a
total attendance of 16,600.
There were ninety-eight individuals reported to
this office as sources of infection by the physicians
of the state of which forty-one were apprehended and
placed under treatment. There w'cre thirty-five
cases referred to this department from other states
and nineteen were apprehended and placed under
treatment.
Beside the regular correspondence, personal letters
were sent out as follows: 99 county attorneys; 64
judges of the district courts; 739 mayors of cities
and towns (two letters); 739 city health officers (two
letters); 200 social workers; 250 public health nurses:
99 county health officers; 1000 rural school teachers.
There will be a federal allotment of $5,116.84 for
the coming year; the state appropriation is $25,000,
making a total of $30,116.84 available for carrj-ing on
the work of venereal disease control.
The following recommendations are made for the
work for the coming year; that, in view of the fact
that the federal government has subsidized the Bu-
reau of Venereal Disease Control of the State of
Iowa in the amount of $5,116.84, the State of Iowa
subsidize the clinics of Iowa to a sum not to exceed
$400, and the same to be contingent upon the local
community spending, at least, double the amount
460
Journal of Iowa State Medical Society
[November, 1922
they are subsidized; and also contingent upon the
size of the town and the work of the clinic; that the
director and the secretary of the State Board of
Health be authorized to inaugurate a method of pay-
ing said money toward the support of the various
clinics, and that this subsidy be used to encourage
other of the large cities to establish clinics.
The director at the request of the Public Health
Service submitted a proposed budget for the coming
year which is as follows:
Administration $ 4,800.00
Treatment 15,600.00
Educational Work 8,716.84
Repressive Measures 1,000.00
Total $30,116.8^
Respectfully submitted,
WILBUR S. CONKLING,
A. A. Surg., U.S.P.H.S.
The starving condition of Russian doctors in the
famine areas, where their help is badly needed, is se-
riously interfering with a vitally important medical
program drawn up by the American Relief Adminis-
tration officials for the benefit of the hunger-stricken
population. Cholera, typhus, malaria, dysentery and
other skin and stomach diseases consequent on mal-
nutrition, are rampant, all through the Volga river
basin, where 30,000,000 people are in acute need, if
not in danger, due to the failure of last summer s
crop. An absolute dearth of medical supplies at first
hampered the work of the American Relief Adminis-
tration, but a grant of $3,000,000 in cash from the
American Red Cross for the purchase of stocks as
well as a further gift of $700,000 worth of surplus
material made, eliminated this difficulty. Now the
call is for personnel which Russia herself can sup-
ply, if only food enough can be found to keep the
workers themselves fit.
“We urge consideration of the possibility of secur-
ing general relief in the form of food remittances
for doctors,” the American Relief Administration ca-
bled recently from Moscow. “This is one of the
most urgent needs to assist the general Russian sit-
uation. We can only secure the best results for our
large and vitally important medical program by us-
ing to tbe maximum extent the Russian doctors
whose condition especially in the famine areas is
desperate. Telegraphic advice of general relief do-
nations for this purpose to make it as far-reachingly
effective as soon as possible would have wonderful
results. I don’t know of any greater service that
our contributors could do than come through right
now with generous donations for this purpose.”
These food remittances which can be bought at
the American Relief Administration offices, 42 Broad-
way, New York, call for the delivery to designated
individuals is Russia of packages, each costing $10,
containing 117 pounds of nourishing food. This in-
cludes flour, rice, cocoa, sugar, cooking fat, tea and
condensed milk, sufficient in each package to keep
an adult well fed for one month. Should the donor
in America not know of any individual to whom he
or she wishes to send such a gift, the remittance can
be made payable to general relief, the beneficiary to
be chosen by the A. R. A. after personal investiga-
tion of his needs.
Already the Jewish Joint Distribution Committee,
in reply to the A. R. A., appeal on behalf of doctors,
has appropriated $25,000 to be spent on remittances
for their relief.
With the available appropriations of $20,847.12, a
new division of extension is being added to the Uni-
versity, a division to be known as that of Maternity
and Infant Hygiene.
Under the Sheppard-Towner act Governor Kendall
appointed the State Board of Education as the agent
through which the law was to be administered. The
State Board of Education has passed on to the
University the burden of the work.
Dr. O. E. Klingaman as director of the new di-
vision presented to the delegates of the Public
Health Conference the plan of the organization and
the relation of public health education and the Shep-
pard-Towner act.
“The budget,” he said, “calls for the employment
of two women physicians and one man physfciaii
who is to be a competent pediatrician, certain clerical
help, and some printing. Much of the work of this
division of Maternity and Infant Hygiene has been
done by the Extension Division in its public health
education and will be supplemented quite largely by
the Extension Division. For this reason, the di-
rector of the extension division is also director of
the Division of Maternity and Infant Hygiene.
“Nurses and medical men are the two agencies
through which our work will be largely done. Ig-
norance of the provisions of the Shepard-Towner
■■\ct is responsible for any opposition it has met from
practicing physicians.
“The work is purely educational. We are not per-
mitted to take children from the home or to place
prospective mothers in hospitals. Neither are we
permitted to employ nurses or physicians for anyone.
It is assumed that we will be permitted to work in
clinics with children under five years of age for this
fiscal year, but after that period the work must be
confined to children under one year.”
The advisory council to the new department is
made up of the following persons: Professor of ob-
stetrics; dean of the college of medicine; professor
of pediatrics; professor of dietetics in the college of
medicine; professor of nutrition in the child welfare
research station; director of the child welfare re-
search station; director of the school of public health
nursing; director of the extension division.
The appropriations made by Congress for the pres-
ent fiscal year are as follows: $5 unmatched to each
state in the Union; and to Iowa (provided the sum is
matched) $26,637.16. The extension division does
not have sufficient funds to match the $26,637.16, but
when the legislature convenes in January it is ex-
pected that the deficit will be provided for.
XII, Xo. 11
Journal of Iowa State Medical Society
401
®f)t Slournal of tlje
3otoa ^tate Jilcbttal ^otictp
D. S. Fairchild, Editor Clinton, Iowa
Publication Committee
D. S. Fairchild Clinton, Iowa
W. L. Bierring Des Moines, Iowa
C. P. Howard Iowa City, Iowa
Trustees
J. W. CoKENOwER Des Moines, Iowa
T. E. Powers Clarinda, Iowa
W. B. Small Waterloo, Iowa
SUBSCRIPTION $2.75 PER YEAR
Books for review and society notes, to Dr. D. S.
Fairchild, Clinton. All applications and contracts
for advertising to Dr. T. B. Throckmorton, Des
Moines.
Office of Publication, Des Moines, Iowa
Vol. XII November 15, 1922 No. 11
VIEWS OF THE LAY PRESS ON DR. de
SCHWEINITZ’ ADDRESS OF ACCEPT-
ANCE AS PRESIDENT-ELECT, A.
M. A., ST. LOUIS
It is recognized as the duty of the state to
provide fundamental education for all citizens
but that the special training for special callings
and professions should be provided for by the
individual himself. On reasonable grounds it
would appear that if the state provides consid-
erable funds for the professional education of
a certain class, the state is entitled to a certain
amount of service in return. This applies to a
certain degree to the medical profession. It is
well known that a considerable part of the ex-
pense of a medical education is borne by the
state, that is, by the public. This being true
the public has a right to expect a certain
amount of service in return, a fact that is ac-
cepted by the real physician, but often forgot-
ten by the purely commercial doctor. The
state, however, does not forget, and the organs
of public opinion — the lay press— take it upon
themselves to keep the public reminded, so
when a great leader in the profession makes a
public address, the press measures up his say-
ing and offers them with its own opinion for
the benefit of the public. Therefore, when a
high official in the American Medical Associa-
tion appears before the public the press brings
the salient points to the attention of the greater
public. Dr. George E. de Schweinitz rendered
the medical jirofession and the jmblic a service
in drawing attention to the relation between
the medical profession and the jniblic, not that
the new age in 'medicine means altogether im-
jiroved methods in treatment, but a new ])olic}'
towards the public in the application of science.
.\s remarked by the W isconsin Medical Jour-
nal, “Some physicians have resisted profes-
sional progress in this line. They would abol-
ish community hospitals and health centers
and maintain the strictly private relation which
consists of treatment when the doctor is
called.”
It must be admitted that a “transition from
individual to organized practice has begun, and
that the movement is rapidly spreading,” which
means that progressive leaders recognize the
public attitude toward accjuired rights of some
of the benefits of medicine as belonging to
humanity, not all to the doctors.
This attitude of the profession to the publu-
does not mean less professional income, indeed,
the respect and confidence in the ideals of tin-
profession will increase the number seekiiu*
medical service.
PROPOSED TARIFF ON MICROSCOPES ANU
SCIENTIFIC APPARATUS
The “Fordney Tariff Bill” (H. R. 7456), introduced
in the House of Representatives on June 29, 1921,
provides an increase to the following rates: (a) mi-
croscopes, photo apparatus, projection apparatus,
field glasses, optical and scientific instruments, 35
per cent, ad valorem; (b) abolishes the privilege to
educational institutions of importing scientific in-
struments free of duty.
The latest form of Tariff Bill H. R. 7456, reported
by Mr. McCumber on April 11, 1922 (now before the
senate committee on finance), reads as follows:
Azimuth mirrors, sextants and octants; photographic
and projection lenses, opera and field glasses, tele-
scopes, microscopes and other optical instruments
and frames and mountings for the same, 55 per cent,
ad valorem (120 per cent increase over the present
rate). Paragraph 360, page 77, reads as follows:
Philosophical scientific, and laboratory instruments,
apparatus, utensils, appliances (including drawing
and mathematical instruments), parts thereof, com-
posed wholly or in chief value of metal, surveying
instruments and parts thereof, 55 per cent ad valorem
(120 per cent increase over the present rate). Para-
graph 1531, page 216, does not provide for duty free
importation of scientific instruments of educational
institutions, therefore automatically cancels this
privilege. — The Boston Medical and Surgical Journal.
462
IOWA STATE UNIVERSITY NEWS NOTES
Don M. Griswold, M.D., Iowa City
The annual volume of “Collected Studies and Re-
ports” of the College of Medicine has just been is-
sued. This volume contains twenty-eight papers sub-
mitted by the various members of the faculty of the
college of medicine, and represents a contribution of
the faculty toward the advancement of medical
science.
IMiss Edna Reitzel has been detailed by the depart-
ment of home economics to the department of in-
ternal medicine, to make advanced studies on nutri-
tion.
Dr. Ruth Okey has resigned from the biochemical
laboratory of the University Hospital, to take up
teaching work in nutrition at the University of Cali-
fornia.
The student health department have finished ex-
amining all candidates for athletic teams that repre-
sent the University and are taking the annual exam-
ination of all freshmen students. This examination
is conducted along the lines of the work of the life
institute and is intended to give the entering student
a proper perspective and interest in his individual
health. This includes a clinical examination of heart,
lungs, reflexes, and a laboratory examination of the
urine, throat, culture, blood-pressure, etc.
Dr. C. S. Chase, for many years in the department
of pharmacology, is now engaged in extension work
for the University Hospital, and the college of med-
icine. This work takes Dr. Chase about the state
where he meets many of his friends and former stu-
dents. Information concerning the educational ad-
vantages of the college of medicine, and the training
school for nurses, can be obtained through Dr. Chase.
Dr. Verne C. Graber has recently been appointed
clinical microscopist in the department of internal
medicine.
Miss Mildred Brown has been promoted to re-
search assistant in the biochemical laboratory.
Dr. Arthur Steindler, professor of orthopedic sur-
gery has returned from an extended trip to Central
Europe. While there he visited many of the large
clinics where American physicians are attending, and
can give first-hand information to any Iowa physi-
cians regarding the present opportunities for clinical
work in Central Europe.
During the summer, President Vincent of the
Rockefeller Foundation, together with a group of his
advisors, visited the medical college and hospital
of the University, and made a careful and thorough
[November, 1922
investigation into the facilities for medical education
as they e.xist here.
Dr. Robert Funston finished a three-year post-
graduate service in orthopedic surgery, and has gone
to Detroit to begin the practice of that specialty.
Harry Mettlock Hines, for some years assistant in
the department of physiology, has received his Ph.D.
and has been made assistant professor of phj’siology.
Miss Edna Bell has taken up her work on the
biochemistry of nutrition, at the children’s hospital.
For some years she was associated wjth President
Mendel of the nutrition laboratory at Yale.
Miss Margery Coast is now in charge of the basal
metabolism laboratory under the direction of Dr.
G. P. Howard. i
Miss Lelah E. Booher, until recently at the Uni-
versity Hospital, has gone to the post-graduate hos-
pital of New York City where she will be assistant
to Dr. Victor E. Meyers.
Dr. A. J. Lomas, superintendent of the University
Hospital has just returned from attending the na-
tional meeting of hospital superintendents at Atlantic
City.
Dr. Harry Dahl, hospital chemist, has received an
appointment as a Fellow at the Rockefeller Institute
in New York City where he will carry out researches
began here.
Miss Josephine Creelman, who was associated with
the nurses’ training school here until six years ago,
has returned and is now superintendent of nurses.
The first year class in the nurses’ training school,
shows a total enrollment of fifty-four. Three of
these girls are college graduates, one has had three
years of college work, one, two years, and four others
have had one year of college work. Two others are
graduates of normal schools, and two more have had
two years of normal training. The others are all
graduates of accredited high schools, from this or
neighboring states. The nurses’ training school Is
being called on each year for an increasing number
of registered nurses, who are college graduates, or
who have had college training, and it is necessary to
have this many or even a larger number, to fill va-
cancies for nurses with this training.
Dr. Samuel T. Orton of the State Psychopathic
Hospital spent his summer vacation on a walking
and fishing trip through ^Montana.
Dr. Vernon Cone has been made research assistant
in the department of neuropathology of the Psycho-
pathic Hospital.
Journal of Iowa State Medical Society
VoL. XII, No. Ill
Journal of Iowa State Medical Society
463
MEDICAL NEWS NOTES
Dr. D. C. Steelsmith, and Dr. W. J. Connell of the
Dubuque city and county health department, have re-
turned from Iowa City where they attended the state
medical conference, held there. The feature of the
meeting was the general favor shown for the system
of public health work being employed in Dubuque
county.
Doctors all over the state were present at the
gathering. Dr. Steelsmith, health director, Dubuque,
was slated for two talks on the program. His ad-
dress on county health work was particularly well
received.
A resolution was passed, recommending the pres-
ident of the State University, the secretaries of the
board of health and the board of education, that a
course for public health experts be introduced at the
State University.
Meeting to revise rules and regulations of the
Iowa State Board of Health, numerous prominent
lowans assembled at the office of Dr. J. J. Hinman,
Jr., chief of the water laboratory division of the
state board, and an S. U. I. faculty member.
The board members were Dr. Charles S. Grant of
Iowa City; President Frank T. Launder, Garner;
Secretary Rpdney P. Fagen, Des Moines; H. C.
Eschbach, .A.lbia; H. Griefe, Des Moines; and H. V.
Pedersen, Des Moines, sanitary engineer.
Dr. Frantz of Burlington, has started a movement
to induce Congress to take some means of extermin-
ating the Mofmon fly that has become such a nui-
sance along the river during the past years. Don’t
say how they are going to do it, but will probably
get an injunction against their congregating in any
large numbers — Donaldson Review.
Dr. G. G. Cottam, Sioux Falls, South Dakota, pre-
sented a report of the veteran bureau committee, rec-
ommending the removal of Gen. C. E. Sawyer, Pres-
ident Harding’s official adviser, as chief of the
federal board of hospitalization on the ground that
General Sawyer is out of sympathy with the work
of the veteran bureau. — Rock Rapids Review.
George \’incent of New York City, president of
the Rockefeller Foundation, was in Iowa City Au-
gust 17 spending the day in conferences with Presi-
dent Walter A. Jessup of the University.
He arrived late from Creston, and will return to
New York .\ugust 18. He and President Jessup
spent part of the day inspecting the University Hos-
pital and the college of medicine.
It was reported that President Vincent was here
in the interests of the Rockefeller Foundation in con-
nection with a proposed appropriation to the medical
department of the University, but President Jessup
stated that Mr. C. Vincent was here on a friendly
visit.
Mr. \'incent has visited several other hospitals be-
fore coming to Iowa City, and left the one at Creston
only yesterday.
The exact nature of the benefit, which the Univer-
sity may derive from the Rockefeller Foundation
could not be determined August 17, although the of
fice of Dr. L. W. Dean, dean of the college of medi-
cine, gave out information that Mr. Vincent was in-
specting the medical department on behalf of the
connection with a proposed donation.
Dr. Dean and Mr. Vincent were together part of
the day with President Jessup, and ate lunch to-
gether.— Iowa City Republican.
WORKMEN’S COMPENSATION LAW IN NEW
YORK AMENDED
One of the most important amendments is the
elimination of the sixty-day limitation for medical
treatment of injured workmen, and a requirement
that the employer furnish to his injured employe
medical care and treatment for as long as the nature
of the injury requires.
SOCIETY PROCEEDINGS
Appanoose County Medical Society
The Appanoose County Medical Society met at
Centerville October 20 at which time a children’s
clinic was conducted by Dr. Albert Byfield of Iowa
City. So successful and valuable to the members
was this clinic that at the business meeting follow-
ing, it was decided to hold an all day clinic, both
medical and surgical, November 15 at St. Joseph’s
Hospital, Centerville. The work of Dr. Byfield was
highly appreciated by the society. At the banquet
following, a musical program was enjoyed.
Buena Vista and Plymouth County Medical Societies
Members of the Buena Vista and Plymouth County
Medical Societies were entertained by the Cherokee
County Medical Society. Those who attended from
this county were Dr. J. H. O’Donoghue and E. E.
Smith of Storm Lake, F. C, Foley and M. A. .Arm-
strong of Newell, C. S. Van Ness of Linn Grove and
J. W. Morrison of Alta.
Dr. Van Ness of Linn Grove gave a talk on “Gen-
eral Management, Clinical Features.”
Greene County Medical Society
Greene County ^ledical Society met Friday, July
28, 1922, at the home of Dr. and Mrs. B. C. Hamilton,
Sr., following attendance at the Tubercular Clinic.
■A picnic supper was enjoyed, following which Dr.
John Peck of Des Moines gave a very instructive
talk on care and treatment of the tubercular.
The following were present. Drs. Kester and
Reed and wives of Grand Junction; Dr. Shipley of
Rippey; Dr. and Mrs. Waddell of Paton; Drs. Cres-
sler, Spear and wives of Churdan; Dr. Presnell of
Scranton; Drs. Hoyt, Hamilton, Jr., Dean, Hamilton,
464
Journal of Iowa State Medical Society
[November, 1922
Sr., and wives of Jefferson; Dr. John Peck of Des
^loines.
Johnson County Medical Society
At a meeting of the Johnson County Medical So-
ciety held September 13 at Iowa City, Dr. C. E. Van
Epps read a paper on Encephalitis; Dr. W. E. Boiler,
on Strabismus, and Dr. P. A. Reed, Pads and Fancies
in Obstetrics.
On October 25 the members of the societj^ were
the guests of the Oakdale Sanitarium, Dr. H. V.
Scarborough, superintendent. Dr. Cuningham read
a paper on Tuberculosis of the Intestines. Dr. Scar-
borough did a pneumothorax and clinical cases were
presented for inspection of the members.
L. G. L.
Jones County Medical Association
The Jones County IMedical Association held an un-
usually successful meeting at the John McDonald
Hospital. Interesting addresses and discussions
were given before the association by Drs. Erskine
and Crawford of Cedar Rapids, and Dr. Charles
Ryan of Des Moines. Following this part of the
program a business session was held, at the close of
which a buffet luncheon was served to the members
of the medical association by Mrs. Gladys Smith
and the nurses of the hospital. The doctors who
were present at the meeting were Dr. William Breen
of Oxford Junction, Dr. Post of Olin, Dr. H. G. Hej-
inian. Dr. W. W. Hunter, Dr. Sigworth and Dr.
Dolan of Anamosa, Dr. Stookey of Olin, Dr. H. Sig-
worth of Waterloo, Dr. Taylor of Prairieburg, Dr.
Knight, Dr. Erskine of Cedar Rapids, Dr. Charles
Ryan of Des Aloines, and Drs. T. M. Redmond, P. E.
Gibson, Harry IMcGarvey, George Wenzlick and W.
J. Cochrane of Monticello.
Pocahontas County Medical Society
At a recent meeting of the Pocahontas County
Medical Association Dr. A. W. Patterson was elected
president, and Dr. A. P. Maloney, secretary.
Tama County Medical Society
Doctors and their wives to the number of about
fifty enjoyed the mid-summer meeting of the Tama
County Medical Society which was held Wednesday
afternoon, July 19, at Toledo, starting with an elab-
orate 1 o’clock dinner in the home dining room.
Program followed the dinner. Dr. A. A. Pace, pres-
ident of the organization, presiding. Dr. Jacob Breid
talked on some of the Indian problems of today, and
Dr. W. F. Hamilton of Marshalltown discussed “Con-
genital Pyloric Stenosis,” presenting exhibits of sev-
eral cases operated on for correction of this diffi-
culty. Dr. C. Van Epps of Iowa City talked on the
subject “Encephalitis.”
Van Buren County Medical Society
The Van Buren County IMedical Societj’ held its
fourth annual picnic Friday, July 14, at Chautauqua
Park, Farmington. About 100 were present, includ-
ing doctors, their families and friends. Physicians
were there from Ottumwa, Keokuk, Burlington, Me-
diapolis, as well as nearly every doctor in Van
Buren county. Dinner was served cafeteria style
about 1 o’clock, after which the following program
was given.
Peptic Ulcer, Dr. L. A. Coffin of Farmington;
Diagnosis of Troubles in Lower Right Quadrant,
Dr. C. R. Armentrout of Keokuk; Infections of the
Hands, Dr. C. H. Magee of Burlington.
Upper Des Moines Medical Association
Wednesday, July 19, the members of the Upper
Des Moines Medical Association held their annual
meeting at the country club near Arnolds Park.
About thirty physicians from Palo Alto, Emmett,
Dickinson and Clay counties were in attendance.
Those who were present from this county were Dr.
Hennessey and Dr. Brereton of Emmetsburg, Dr.
Houston of Ruthven, and Dr. Morrison of Ayrshire.
The program was as follows:
Duty of the Medical Profession to the Public, Dr.
G. C. Fuller, Milford.
Anomalies of the Esophagus, Dr. Thos. Kas,
Sutherland.
Address of President, Dr. E. W. Sproule, Peterson.
Some Problems of Infant Feeding, Dr. J. D. Geis-
singer, St. Paul.
Dr. Gessinger is a specialist on infantile ailments.
He practiced at Spirit Lake for several years.
Aneurysm of Abdominal Aorta, Dr. AI. T. Alorton,
Estherville. .
Iowa Surgical Society
The Iowa Surgical Society met with Dr. W. A.
Rohlf of Waverly July 29. There were about twenty
surgeons present.
AMERICAN SURGICAL ASSOCIATION
At the annual meeting of this association in Wash-
ington, D. C., recently. Dr. Lewis L. McArthur, Chi-
cago, was elected president; Drs. Ellsworth Eliot, Jr.,
New York and Dr. Donald C. Balfour, Rochester,
Minnesota, vice-presidents; Dr. Robert B. Greenough,
Boston, secretary, and Dr. Charles H. Peck, New
York, treasurer. The next meeting of the associa-
tion will be held in Rochester, Alinnesota, in June,
1923.
HOSPITAL NOTES
Dr. Conreid Rex Harken of Osceola, a former Iowa
City physician and surgeon, is planning to remodel
his hospital, in that city, and make it one of the
finest institutions of its type in Iowa as to equip-
ment and arrangement.
The structure, three stories high, will be raised
VoL. XII, Xo. 11 1
Journal of Iowa State Medical Society
465
three feet above its present foundation, and will be
reconstructed from basement to roof.
W. L. Steele, Siou.x; City architect, has been com-
missioned by the building committee of the Sisters
of ^lercy Hospital at Cedar Rapids to design a new
building there, the cost of the structure to be ap-
proximately $250,000.
The proposed building will increase the capacity of
that hospital from 100 to 200 beds. Construction will
be entirely of fireproof materials, with all modern
conveniences. Brick, steel and reinforced concrete
will be used throughout.
Mr. Steele will plan the new part of the hospital
so that it will be the most convenient and sanitary
arrangement that can be had.
.■\ctual building operations will start in the fall,
with expectations of the project being finished next
year.
Funds already have been subscribed to pay for the
completion of the structure.
Standardizing of Hospitals Urged
A plea for the standardization of the hospitals of
America was voiced last evening by Dr. L. D. Moore-
head, dean of Loyola Medical College, Chicago,
and vice-president of the Catholic Hospital Associa-
tion of the United States and Canada. Dr. Moore-
head spoke to the medical men of Waterloo at the
annual staff dinner given by the Franciscan sister,•^
in charge of St. Francis Hospital. Other speak-
ers were Archbishop .1. T. Keane of the Dubuque
diocese, and Father P. ]. Mahan, Chicago, president
of the state conferences of the Catholic Hospital As-
sociation, the latter imparting much wholesome ad-
vice to the assembled physicians.
Mr. ^loorehead stressed the need for standardiza-
tion of American hospitals from the standpoint of its
practical worth to the physician and other hospital
workers as well as the great benefit the public would
derive as a result. He declared there were but seven-
teen such standardized hospitals in America at
present.
Archbishop Keane paid a wonderful tribute to the
modern day physician and surgeon, who, through
painstaking study and research work, have rendered
such a great service to the human race. While the
work of all hospitals was lauded by the speakers,
each declared the sisters in Catholic hospitals, who
labored without compensation other than that which
comes in the fulfillment of their mission of love and
sacrifice, were entitled to special credit..
Rev. H. P. Rohlman, Dubuque, was also a guest at
the banquet as were the members of the Catholic
clergy of this city, .\bout thirty-five physicians and
surgeons were in attendance and at the conclusion of
the address a rising vote of thanks was given the
speakers for their kindness in appearing on the pro-
gram, and to the sisters for excellent entertainment
and banquet they had prepared.
PERSONAL MENTION
Dr. H. L. Wyatt and family have removed to the
Orient. For some time he has been in the navy sta-
tioned at San Diego, California.
Dr. Guy B. Anderson has purchased the ]>ractice of
Dr. I. E. Ballachy of Swea City.
Dr. M. H. Lynch formerly of Perry has ]nirchased
the equipment of the late Dr. Chas. B. Burke of At-
lantic.
Dr. Herman Fischer of Burlington has moved to
southern California. Dr. Fischer is a specialist in
diseases of the eye, ear, nose and throat.
Dr. R. W. Henderson, a graduate from Iowa L’ni-
versity medical school 1921, will locate at Lone Tree,
Johnson county.
Dr. H. C. Yates formerly of Emerson has moved
to Mount Vernon where he will continue in the prac-
tice of medicine.
Dr. W. Hodges has been transferred from tlm
government hospital at Colfa.x to the hospital at
Newport, Kentucky, and Dr. Graham has been trans-
ferred from Newport to Colfax.
Dr. H. F. Dunn of Stone City has located at Sibley.
Dr. C. A. Brandt of Dysart has sold his practice
and office equipment to Dr. W. C. Wagner of Traer.
Dr. T. J. Plase recently graduated from the Iowa
State University School of Medicine will locate in
Washington, Iowa.
Dr. T. J. Burke, who has sold his practice, will
soon move to Wichita, Kansas. Dr. Burke has prac-
ticed in DeWitt twenty-two years. Dr. and Mrs.
L. O. Riggert of Omaha, Nebraska, who recently
purchased the practice of Dr. T. I. Burke will move
into the Elder cottage in West DeWitt.
Dr. L. L. Henninger of the firm of Drs. Dean anil
Henninger, Council Bluffs, for the past twelve years,
has accepted a partnership with Dr. J. R. Reed of
Pasadena, California. Mrs. Henninger and two chil-
dren will accompany Dr. Henninger west about Oc-
tober 20. Dr. Henninger is entering a much larger field
with increased business opportunities. Los .\ngeles
was Mrs. Henninger's home and she has a father and
two sisters living there at this time. Dr. L. G.
Howard, who has been one of the firm for the past
year and a half will continue his association with Dr.
Dean.
Dr. H. B. Jennings, for many years physician in
Council Bluffs announced .\ugust 10 that he would
retire from practice at once. He has been practicing
in this city for thirty-three years and prior to that in
eastern Iowa seven years.
Dr. Warden Rimels has recently located in Bed-
ford.
Dr. E. \\'. Sproule of Peterson has sold his prop-
erty and practice to Dr. E. A. Nash of Bristow and is
taking a post-graduate course in Chicago after which
he will locate in the West. Dr. Nash has also taken
a post graduate course recently.
Dr. T. E. Powers of Clarinda was nominated by
the republican central committee of Page county for
466
Journal of Iowa State Medical Society
[November, 1922
representative in the Iowa general assembly to suc-
ceed Representative J. H. Stirnson, who died re-
cently. The democrats have no candidate on their
ticket for representative.
Lieut. T. F. Duhigg, U. S. X., will sail from San
Francisco September 5 for a two-j'ear cruise about
the world with the Asiatic fleet of the L^nited States
Xavy. His place here as examining surgeon for the
naval recruiting office has been taken by Lieut.
Zacariah A. Barker.
Dr. Gershom H. Hill, accompanied by Mrs. Hill
and their daughter, Dr. Julia F. Hill,- are motoring
to points in Minnesota and will go to Lake Itasca be-
fore returning home.
Joseph Mayo of Rochester, Minnesota, son of
Charles Mayo, one of the famous Mayo brothers of
the Mayo hospitals at Rochester, klinnesota, is now-
taking pre-medic w-ork at the University of Iowa and
is expecting to continue the course next year.
Dr. and Mrs. R. H. Stafford and son, Howard, de-
parted klonday morning, August 7, for their new'
home at Long Reach, California. Dr. Stafford will
open a practice there.
Dr. C. Corbin Yancey of Chicago, has taken Dr.
John W. Shuman’s office suite in the Frances build-
ing, Sioux City, and will continue the practice of in-
ternal medicine, x-ray, diagnoses and consultation.
Dr. Yancey is a graduate of the University of Chi-
cago, where he received his degree of bachelor of
science. He completed his medical course at Rush
^Medical College. He served as resident physician of
the Allegheny General Hospital, at Pittsburgh, Penn-
sylvania, and has done other important post-graduate
w'ork. Miss Maud Fair, who has been secretary and
technician for Dr. Shuman for nine years, w'ill con-
tinue her work wdth Dr. Yancey.
Dr. George H. Scalon has returned from Harper
Hospital, Detroit, Michigan, where he has been serv-
ing as an interne, during the last year. Prior to that
he filled a similar position at Mercy Hospital, Iowa
City. He is an alumnus of the college of medicine.
S. U. L, class of 1921. He will locate in Iowa City,
and will be associated wdth Dr. W. R. White, in the
practice of medicine and surgery.
Dr. Lawrence Littig and his w-ife, who have spent
their honeymoon at the home of Dr. Littig’s mother,
Mrs. L. W. Littig, have returned to make their home
in Madison, Wisconsin. The wedding of these young
people occurred in Rock Island on Saturday, July
22. The bride was formerly Miss Elsie Rosanske of
Madison, Wisconsin, an alumnus of the University of
Wisconsin, where Dr. Littig also attended school for
a few years and where he affiliated with the Delta
Upsilon fraternity. He received his degree from the
college of medicine of the L’niversity of Iowa in 1921
and since that time has been an interne in the Gen-
eral Hospital in Madison. Xow he is house surgeon
at the same institution.
Dr. J. Vincent Smith, who for the past tw'o years
has been associated with Dr. Weston of Des Moines,
has purchased the practice of Dr. M. H. Lynch, to-
gether with his office equipment, library, etc., and
has located in Perry for the practice of his profes-
sion. He has leased the Lynch office building on
Willis avenue.
Dr. Herbert Pease of Slater has removed to Web-
ster City.
Dr. T. R. Campbell of Rolfe has located at Sioux
Rapids.
Dr. W. J. Cochrane of Monticello has removed to
Lake City, Minnesota.
Dr. L. S. Deitrich of Marengo has removed to
Medford, Wisconsin, becoming a member of the
staff of the Medford Clinic.
The Council has appointed Dr. A. C. Page, De-^
Moines, treasurer of the Iowa State Medical Society
to succeed Dr. Thos. F. Duhigg, who resigned on
leaving for a cruise with the Asiatic Fleet of the
U. S. X., September 1.
OBITUARY
Dr. B. C. Stewart of Ute died in a Lincoln, Ne-
braska, hospital August 13 from heart disease.
Dr. Sarah J. Weston a pioneer physician of Fort
Dodge died at Fort Dodge August 1 at the age of
eighty-one years. She came to Iowa in 1865, lived in
Des Moines, Webster City and Fort Dodge.
Dr. Thos. Croston of Lucas died at his home Au-
gust 19, 1922 at the age of seventy-six years.
Dr. Philip Francis Harvey, a former resident of
Burlington, died June 5. He was one of the best
known members of the medical staff of the United
States army, seeing service in the Civil War, the
Sioux Indian Wars, the Spanish American War and
the Philippine insurrection.
He was seventy-eight years of age and was grad-
uated from the State University of Iowa College of
Medicine in 1864, was on the staff of the Bellevue
Hospital Medical College, New York City, in 1866.
He was a professor of surgery at the National Uni-
versity Medical Department, Washington, D. C.,
1866 to 1868. He was a member of the Association
of Military Surgeons, Society of Foreign Wars and
the Society of the Army of the Potomac.
He spent a useful, busy life in the army service
and was retired in 1908.
Dr. D. W. Swigert, the pioneer physician of Fre-
mont county, passed away at his home in Hamburg,
Saturday aft-ernoon at the age of ninety-one.
He was a graduate of the St. Louis Medical College
and took post-graduate work in the Rush Medical
College and Bellevue IHedical College of New York.
Dr. M. F. Hannelly died at his home at Mt. Ayr
at 10:30 o’clock Monday night August 9, after an ill-
ness of over a year. He was raised in Ringgold
county, and has been practicing medicine at Mt. Ayr
\'0L. XII, Xo. 1 1 1
Journal of Iowa State Medical Society
467
for a period of twelve years. His illness which thus
terminated in his death, was occasioned by Bright’s
disease.
Albert Franklin Bonney was born in Canada, Au-
gust 5, 1863, died at his home in Buck Grove, June
30, 1922, aged sixty-eight years and eleven months.
He was the eldest son of Charles S. Bonney and
Mary Greenleaf Bonney. His early years were spent
with his parents in New York state and Pennsyl-
vania. As a young man he came to Iowa and in 188U
was married to Miss Fannie O’Neill at Dubuque.
Iowa. To this union four children were born.
Dr. Bonney was a man with an exceptionally bril-
liant mind. He was a very successful physician for
years until his health failed, and he was obliged to
give up active practice. Of late years he has de-
voted the winter months to literar}- pursuits and the
summer time to bee keeping. He was president of
the Iowa Beekeepers Association for several years
and was considered an authority on that industry all
over the world. He was a very successful writer, not
only of fiction, but of heavy scientific articles. He
has been in gradually failing health for a year.
Dr. F. J. Drake, fifty-three years old, for twenty-
six years a resident physician of Webster City and
prominent in religious, social, and lodge circles, was
found dead in his office about 10:30 o’clock Septem-
.ber 1.
Franklin J. Drake was born October 4, 1869 in
Kingsville, Ontario, Canada. He was the son of
Joseph and Sarah Drake and his mother died at his
birth. Two years later, his father, then a practicing
physician and surgeon removed from Canada to Mt.
Vernon, Iowa, and there resided until his death in
1906. His education was obtained in the public
schools of Mt. Vernon and in Iowa Wesleyan Uni-
versity at Mt. Pleasant. Later he took a medical
course in the Chicago Homeopathic Medical School
of Chicago, graduating from this in 1895. Imme-
diately after this, he located in Webster City and the
same year was married to Miss Edna E. Smith, the
daughter of Rev. and Mrs. Samuel C. Smith of the
Methodist Church of Mt. Pleasant.
Dr. John Aaron Rawlins, son of Lemmon Parker
and Julia Rawlins, was born at Gulford, Jo Davess
county, Illinois, April 20, 1866. His common school
education in Guilford was followed by work in the
German-English Normal School in Galtna and two
years’ study in the State Normal School, Normal,
Illinois, after which he took the three years’ medical
course at Rush College at that time required for a
degree in medicine, graduating in February, 1888, at
the age of twenty-two. The next three years’ he
worked with Dr. Albert Green of Shullsburg, Wis-
consin, where he established a home, having married
in 1889, Miss Carrie Livonia King, of Warren, Il-
linois. In 1892 Dr. and Mrs. Rawlins moved to
Chickasaw county, Iowa, which proved to be the
chief scene of the next twenty-nine years of his ser-
vice as a physician; thirteen years at Bassett; four
and a half years at Clear Lake, and ten years at
Ionia. This long period of activity was interrupted
only twice: first, when he pursued a course of clinical
instruction in the Chicago Policlinic, for which he re-
ceived a certificate of completion in December, 1897;
and again after the residence at Clear Lake, when he
traveled and rested for a year in Colorado. Dr.
Rawlins had been more or less subject to asthma
complicated with emphysema and this together with
the strain due to the overtaxing of his strength dur-
ing the influenza epidemic caused a break in his
health that led to his withdrawal from active prac-
tice about two years ago, 1920. In the hope of re-
cuperating he lived quietly for a time in Charles City,
then moved to Davenport where he erected an at-
tractive house of Queen Ann style, and looked for-
ward to spending the remainder of his life.
MARRIAGES
Dr. H. C. Hibben, formerly of Davenport and Miss
Marjorie McCollins of Davenport, were married at
Dubuque, July 22, 1922.
Dr. Lola Clark Mighel and Mr. Glenn Kenderdine
were married in Cedar Rapids, July 29 at the home of
Rev. Burkhalter, who read the marriage service.
Both Mr. and Mrs. Kenderdine are residents of Iowa
City and graduates of the University of Iowa in law
and medicine respectively.
In addition to the articles enumerated in our letter
of September 1, 1922, the following articles were ac-
cepted during August:
H. K. Mulford Company:
Mercurialized Serum No. 2 — Mulford.
Mercuric Succinimide Hypodermic Tablets No.
50.
Parke, Davis and Company:
Adrenalin and Cocaine Tablets Rx B.
,'\drenalin Tablets No. 2.
Brometone Capsules, 5 grains.
Tuberculin (old) and Control for the Von Pir-
quet Test.
Tuberculin Ointment for the Moro Test.
During September the following articles have been
accepted by the Council on Pharmacy and Chemistry
for inclusion in New and Non-official Remedies:
H. A. Metz Laboratories:
Novocain and L-Suprarenin Tablets “H”.
Novocain Solution, 1 per cent.
Novocain Base.
Novocain Nitrate.
Pyramidon Tablets.
United States Radium Corporation:
Ampules Radium Chloride 2 Cc — U. S. Radium
Corp. (Radium element, 5 micrograms.
Ampules Radium Chloride 2 Cc — U. S. Radium
Corp. (Radium Element, 10 micrograms).
■Ampules Radium Chloride 2 Cc — U. S. Radium
Corp. (Radium element, 25 micrograms).
Winthrop Chemical Company:
Fereo — Sajodin.
468
Journal of Iowa S i ate Medical Society
[XOVEIIBER, 1922
CONSTITUTION AND BY-LAWS OF THE
IOWA STATE MEDICAL SOCIETY
CONSTITUTION
ARTICLE I
Name of the Society
The name and title of this organization shall be
the Iowa State Medical Society.
ARTICLE II
Purposes of the Society
The purpose of this Societj" shall be to federate
and bring into one compact organization the entire
medical profession of the State of Iowa, and to unite
with similar associations in other states to form the
.\merican Medical Association, with a view to the
extension of medical knowledge and to the advance-
ment of medical science, to the elevation of the
standard of medical education and to the enactment
and enforcement of just medical laws, to the pro-
motion of friendly intercourse among phj-sicians and
to the guarding and fostering of their material in-
terests, and to the enlightenment and direction of
public opinion in regard to the great problems of
state medicine; so that the profession shall become
more capable and honorable within itself, and more
useful to the publie in the prevention and cure of
disease, and in prolonging and adding comfort to
life.
ARTICLE III
Component Societies
Component societies shall consist of those county
medical societies which hold charters from this
Society.
ARTICLE IV
Composition of the Society
Section 1. This Society shall consist of ^lembers.
Associate Members, Delegates, Guests, and Life
Members.
Sec. 2. Members — The members of this Society
shall be the members of the component county med-
ical Societies.
Sec. 3. Delegates — Delegates shall be those mem-
bers who are elected in accordance with this Con-
stitution and By-Laws to represent their respective
component county societies in the House of Dele-
gates of this Society.
Sec. 4. Guests — Any distinguished physician, not
a resident of this state, may become a guest during
any Annual Session upon invitation of the Society or
its Council, and shall be accorded the privilege of
participating in all of the scientific work for that
session.
Sec. 5. Life Members — Life members shall con-
sist of such members in good standing as shall have
paid their full annual dues, and all other obligations
to the Society, for thirty successive years, and of
such other worthy members as the Society maj’
designate by unanimous vote. They shall receive
the transactions of the Society, and enjoy all the
privileges of members, but shall be excepted fron;
payment of the annual dues.
Sec. 6. Associate Members — Teachers in any reg-
ular medical school, resident in Iowa, in no manner
engaged in the practice of medicine, and not other-
wise eligible to regular membership, may become
associate members of this Society, when elected as-
sociate members of the component society of the
county in which said teachers live. Such members
shall be designated associate members; they shall en-
joy the same privileges as regular members and shall
be subject to the same conditions.
ARTICLE V
House of Delegates
The House of Delegates shall be the legislative
and business body of the Society, and shall consist
of (1), delegates elected by the component county
societies, and (2), ex-officio, the officers of the So-
ciety as defined in this Constitution.
ARTICLE VI
Sections and District Societies
The House of Delegates may provide for a divi-
sion of the scientific work of the Society into ap-
propriate sections; and for the organization of such
councilor district societies as will promote the best
interests of the profession, such societies to be com-
posed exclusively of members of component county
societies.
ARTICLE VII
Sessions and Meetings
Section 1. The Society shall hold an Annual Ses-
sion, during which there shall be held daily not less
than two general meetings, whicii shall be open to
all registered members, delegates, and guests.
Sec. 2. The time and place for holding each
Annual Session shall be fixed by the House of
Delegates.
ARTICLE VIII
Officers
Section 1. The officers of this Society shall be a
President, two Vice-Presidents, a President-Elect, a
Secretary, a Treasurer, eleven Councilors and three
Trustees.
Sec. 2. The President-Elect and \’ice-Presidents
shall be elected for a term of one year, the Secre-
tary and Treasurer for three years, and the Coun-
cilors for five years — the Councilors being divided
into classes so that two shall be elected each year.
The Trustees shall be elected for three years, one
VoL. XII, No. 11]
Journal of Iowa State Medical Society
469
each year. All these officers shall serve until their
successors are elected and installed.
Sec. 3. The officers of this Society shall be
elected by the House of Delegates on the morning
of the last day of the Annual Session, but no dele-
gate shall be eligible to any office named in the
preceding section, except that of the Councilor and
Trustee, and no person shall be elected to any office
who is not in attendance upon that Annual Session
and who has not been a member of the Society for
the past two years.
Sec. 4. At the election of officers at the session
of 1915 there shall be elected a President who shall
enter upon the duties of his office at once, and also
a President-Elect who shall enter upon the duties of
the Presidency one year later. Thereafter, the Presi-
dent-Elect shall enter upon the duties of the Presi-
dency one 3^ear from the date of his election.
ARTICLE IX
Funds and Expenses
Funds for meeting the expenses of the Society
shall be arranged for by the House of Delegates by
an equal per capita assessment upon each county
society to be fixed by the House of E>elegates, by
voluntary contribution, and from the profits of its
publications. Funds may be appropriated by the
House of Delegates to defray the expenses of the
Annual Sessions, for publication, and for such other
purposes as will promote the welfare of the Society
and profession.
ARTICLE X
Referendum
At any general meeting the Society may, by a
two-thirds vote, order a general referendum upon
any question pending before or passed by the House
of Delegates, and the House of Delegates shall, by
a similar vote of its own members, or after a like
vote of a general meeting, submit any such question
to the membership of the Society for a final vote.
majority of the members voting shall decide the
question and be binding on the House of Delegates.
ARTICLE XI
The Seal
The Society shall have a common seal, with power
to break, change, or renew the same at pleasure.
ARTICLE XII
Amendments
The House of Delegates may amend any article of
this Constitution by a two-thirds vote of the dele-
gates registered at the Annual Session, provided that
such amendment shall have been presented in open
meeting at the. previous Annual Session and shall
have been published in the Journal of this Society.
BY-LAWS
CHAPTER I
Membership
Section 1. All members of the component county
societies shall be privileged to attend all meetings
and take part in all of the proceedings of the An-
nual Sessions, and shall be eligible to any office
within the gift of the Society.
Sec. 2. The name of a physician upon the prop-
erly certified roster of members, or list of delegates,
of a chartered county society which has paid its
annual assessment, or a receipt for dues for the
current j-ear from the Secretary or Treasurer of the
county society to which he belongs, shall be prima
facie evidence of his right to register at the Annual
Session in the respective bodies of this Society.
Sec. 3. No person who is under sentence of sus-
pension or expulsion from any component society
of this Society, or whose name has been dropped
from its roll of members, shall be entitled to any
of the rights or benefits of this Society, nor shall
he be permitted to take part in any of its proceed-
ings until such time as he has been relieved of such
disability.
Sec. 4. Each member in attendance at the Annual
Session shall enter his name on the registration book,
indicating the component society of which he is a
member. No member or delegate shall take part in
any of the proceedings of an Annual Session until he
has complied with the provisions of this section.
Sec. 5. For the purpose of medical defense a
member shall be regarded as in good standing only
when his dues have been received by the Secretary
of the State Society; nor shall any member under
suspension or expulsion be eligible to the benefits
of the medico-legal fund for any alleged wrongful
act while under suspension or expulsion.
Sec. 6. If the annual report and the per capita
apportionment of any component society is not re-
ceived by the Secretary of the State Society for two
consecutive years, then the charter of that society
shall be automatically revoked, and the Secretary of
the State Society shall notify the Secretary of such
society, to that effect.
CHAPTER II
Annual and Special Sessions of the Society
Section 1. The Society shall hold an Annual Ses-
sion at such time and place as has been fixed at the
preceding Annual Session by the House of Delegates.
Sec. 2. Special sessions of either the Society or
the House of Delegates shall be called by the Presi-
dent at his discretion or upon petition of twenty
delegates.
Sec. 3. The fiscal year of this Society shall be
the calendar year.
4/0
Journal of Iowa State Medical Society
[November, 1922
CHAPTER III
General Meetings
Section 1. The general meetings shall include all
registered members, delegates, and guests, who shall
have equal rights to participate in the proceedings
and discussions, and, except guests, to vote on pend-
ing questions. Each general meeting shall be pre-
sided over by Jhe President, or in his absence or dis-
ability, or by his request, by one of the Vice-Presi-
dents. Before it, at such time and place as may have
been arranged, shall be delivered the annual address
of the President and the annual orations, and the
entire time of the session, so far as may be, shall be
devoted to papers and discussions relating to scien-
tific medicine.
Sec. 2. The general meeting shall have authority
to create committees or commissions for scientific
investigations of special interest and importance to
the profession and public, and to receive and dispose
of reports of the same; but any expense in connec-
tion therewith must first be approved by the House
of Delegates.
Sec. 3. Except by special vote, the order of exer-
cises, papers, and discussions as set forth in the offi-
cial program shall be followed from day to day until
it has been completed.
Sec. 4. No address or paper before the Society,
except those of the President, Guests, and Orators,
shall occupy more than twenty minutes in its de
livery; and no member shall speak longer than five
minutes nor more than once on any subject.
CHAPTER IV
House of Delegates
Section 1. The House of Delegates shall meet
annually at the time and place of the Annual Ses-
sion of the Society, and shall so fix its hours of
meeting as not to conflict with the first general
meeting of the Society, or with the meeting held for
the address of the President and the annual orations,
and so as to give delegates an opportunity to attend
the other scientific proceedings and discussions so
far as it is consistent with their duties. But if the
business interests of the Society and the profession
require, it may meet in advance, or remain in -session
after the final adjournment of the general meeting.
Sec. 2. Each component county society shall be
entitled to send to the House of Delegates each year,
one delegate for every fifty members, and one for
each major fraction thereof, but each county society
holding a charter from the Society, which has made
its annual report and paid its assessment as provided
in this Constitution and By-Laws, shall be entitled to
one delegate.
Sec. 3. A majority of the registered delegates and
officers shall constitute a quorum; and all of the
meetings of the House of Delegates shall be open to
members of the Society.
Sec. 4. It shall through its officers, advisory, and
councilors, consider and advise as to the material
interests of the profession, and of the public in those
important matters wherein it is dependent upon the
profession and shall use its influence to secure and
enforce all proper medical and public health legisla-
tion and to diffuse popular information in relation
thereto.
Sec. 5. It shall make careful inquiry into the con-
dition of the profession of each county in the state,
and shall have authority to adopt such methods as
may be deemed most efficient for building up and
increasing the interest in such county societies as al-
ready exist, and for organizing the profession in
counties where societies do not exist. It shall es-
pecially and systematically endeavor to promote
friendly intercourse between physicians of the same
locality and shall continue these efforts until every
physician in every county of the state, who can be
made reputable, has been brought under medical so-
ciety influence.
Sec. 6. It shall elect representatives to the House
of Delegates of the American Medical Association
in accordance with the Constitution and By-Laws
of that body in such a manner that not more than
one-half of the delegates shall be elected in any one
year.
Sec. 7. It shall, upon application, provide and is-
sue charters to county societies organized to con-
form to the spirit of this Constitution and By-Laws.
Sec. 8. In sparsely settled sections it shall have
authority to organize the physicians of two or more
counties into societies to be designated by hyphen-
ating the names of two or more counties so as to
distinguish them from district and other classes of
societies, and these societies, when organized and
chartered, shall be entitled to all the privileges and
representation provided therein for county societies,
until such counties may be organized separately.
Sec. 9. It shall have authority to appoint com-
mittees for special purposes from among members
of the Society who are not members of the House
of Delegates, and such committees may report to
the House of Delegates in person, and may partici-
pate in the debate thereon.
Sec. 10. It shall approve all memorials and reso-
lutions issued in the name of the Society before the
same shall become effective.
Sec. 11. It shall present, through the Secretary,
a summary of its proceedings to the last general
meeting of each Annual Session, and shall publish the
same in the transactions.
CHAPTER V
• Election of Officers
Section 1. All elections shall be by secret ballot,
and a majority of the votes cast shall be necessary
to elect.
VoL. XII, No. Ill
Journal of Iowa State Medical Society
471
Sec. 2. On the first day of the Annual Session,
there shall be selected a Committee on Nominations
consisting of eleven delegates, one from each con-
gressional district. Such committee shall be selected
by the delegates of each congressional district in
separate caucuses, and such caucuses shall at the
same time select the member of the Council for the
same district. It shall be the duty of this committee
to consult with the members of the Society and to
hold one or more meetings at which the interests of
the Society and the profession of the state for the
ensuing year shall be carefully considered. The
committee shall report the result of its deliberations
to the House of Delegates in the shape of a ticket
containing the names of three members for the office
of President-Elect (in 1915 President also), and one
member for each of the other offices to be filled at
that annual election. Two candidates for President-
Elect shall not be named from the same county.
Sec. 3. The report of the Nominating Committee
and the election of officers shall be the first order
of business of the House of Delegates, after the
reading of the minutes, on the third day of the
general session.
Sec. 4. Nothing in this article shall be construed
to prevent additional nominations being made by
members of the House of Delegates.
CHAPTER VI
Duties of Officers
Section 1. President: The President shall pre-
side at all meetings of the Society and of the House
of Delegates; shall appoint all committees not other-
wise provided for; shall deliver an annual address at
such time as m.ay be arranged; shall give a deciding
vote in case of a tie, and shall perform such other
duties as custom and parliamentary usage may re-
quire. He shall be the real head of the profession of
the state during his term of office, and as far as prac-
ticable shall visit, by appointment, the various sec-
tions of the state and assist the Councilors in build-
ing up the county societies, and in making their
work more practical and useful.
Sec. 2. Vice-Presidents: The Vice-Presidents,
when called upon, shall assist the President in the
performance of his duties, and during his absence,
or at the request of the President, one of them shall
officiate in his place. In the case of death, resigna-
tion, or removal of the President, the vacancy shall
be filled by the Senior Vice-President beginning with
the first. They shall perform all other duties pre-
scribed for that office.
Sec. 3. Treasurer: The Treasurer shall give bond
in such sum as shall be determined by the Board of
Trustees; such bond to be procured from some re-
liable security company by the Trustees and to be
approved by the Board of Trustees. The expense of
procuring such bond shall be paid by this Society, and
the bond shall be held b\- the Board of Trustees. All
surplus mone\' in the hands of the Treasurer shall be
placed at interest in some bank approved by the
Board of Trustees, or invested in United States
bonds, and such interest shall be turned into the
Treasury of the Society. The Treasurer shall demand
and receive all funds due the Society from the Sec-
retary, together with any bequests and donations.
He shall pay money out of the Treasury only on a
written order of the President, countersigned by the
Secretary, and approved by the Board of Trustees.
He shall subject his accounts to such examination as
the House of Delegates may order, and he shall an
nually render an account of his doings and of the
state of the funds in his hands. He shall charge
upon his books the assessment against each compo-
nent society at the end of the fiscal year; he shall
collect and make proper credits for the same, and
perform such other duties as may be assigned to him.
The amount of the Treasurer’s salarj- shall be fixed
by the House of Delegates and shall be paid annually.
Sec. 4. Secretary: The Secretary, acting with the
committee on scientific work, shall prepare and issue
the programs for, and attend all meetings of, the So-
ciety and of the House of Delegates; he shall
keep minutes of their respective proceedings in
separate record books and papers belonging to the
Society, except such as properly belonging to the
Treasurer. He shall collect all assessments against
each component society, and shall keep account of,
and promptly turn over to the Treasurer, all funds
of the Society w'hich come into his hands. He shall
provide for the registration of the members and dele-
gates at the Annual Sessions. He shall keep a card
index register of all the legal practitioners of the
state by counties, noting on each his status in rela-
tion to his county society, and upon request shall
transmit a copy of this list to the American Medical
Association for publication. In so far as it is in his
power he shall use the printed matter, correspond-
ence, and influence of his office, to aid the Councilors
in the organization and improvement of the county
societies and in the extension of the power and use-
fulness of this Society. He shall conduct the official
correspondence, notifying members of meetings, of-
ficers of their election, and committees of their ap-
pointment and duties. He shall employ such assist-
ance as may be ordered by the Council or the House
of Delegates. He shall annually make a report of his
doings to the House of Delegates. In order that the
Secretary may be enabled to give that amount of time
to his duties which will permit of his becoming pro-
ficient, it is desirable that he should receive some
compensation. The amount of his salary shall be
fixed by the House of Delegates, and shall be paid
quarterly. He shall give bond in the sum of $5,000.00,
such bond to be procured from some reliable securit\
company by the Trustees and to be approved by the
Board of Trustees. The expense of such bond shall
be paid by the Society.
Sec. 5. Trustees: The Board of Trustees shal'
have charge of the property and financial affairs of
472
Journal of Iowa State Medical Society
[November, 1922
the Societ}-, and shall meet quarterly, the expenses of
such meetings to be paid by the Society as provided
in Section 4, Chapter IX of the By-Laws; but this
shall not be construed to include the expenses in
attending the Annual Sessions.
CHAPTER VII
Duties of the Council
Section 1. The Council shall hold daily meetings
during the Annual Session of the Society, and at
^uch other times as necessity may require, subject to
the call of the chairman or on petition of three
Councilors. It shall meet on the last day of the
•Annual Session of the Society for re-organization
and for the outlining of work for the ensuing j^ear.
At this meeting it shall elect a chairman and sec-
retary, and it shall keep a permanent record of its
proceedings. It shall, through its chairman, make an
annual report to the House of Delegates at such
time as may be provided.
Sec. 2. Each Councilor shall be organizer for his
district. He shall visit each county in his district at
least once a year for the purpose of organizing
component societies where none exist, for inquiring
into the condition of the profession, and for improv-
ing and increasing the zeal of the county societies
and their members. The Councilor majq when ad-
visable, appoint a deputy or deputies to assist him
in his work to carry out the requirements of this
section. He shall make an annual report of his do-
ings, and of the condition of the profession of each
county in his district, to each Annual Session of the
House of Delegates. The necessary traveling, and
other actual expenses, incurred by such Councilor or
his deputy, or deputies, in the line of the duties
herein imposed, having been approved by the Board
of Trustees, shall be allowed by the House of Dele-
gates upon a proper itemized statement, but this
shall not be construed to include his expenses in at-
tending the .Annual Session of the Society.
Sec. 3. Collectively, the Council shall be the
Board of Censors of the Society. It shall consider
all questions involving the rights and standing of
members, whether in relation to other members, to
the component societies, or to this Society. All
questions of an ethical nature brought before the
House of Delegates of the general meeting shall be
referred to the Council without discussion. It shall
hear and decide all questions of discipline affecting
the conduct of members, or of a county society, upon
which an appeal is taken from the decision of an in-
dividual Councilor. Its decision in all such cases
shall be final.
Sec. 4. The Council shall have the right to com-
municate the views of the profession and of the
Society in regard to health, sanitation, and other im-
portant matters, to the public and the lay press.
Such communications shall be officially signed by
the chairman and secretary of the Council, as such.
CHAPTER Vni
Committees
Section 1. The standing committees shall be as
follows:
A committee on scientific work. (3)
A committee on public policy and legislation. (5)
.A committee on publication. (3)
.A committee on necrology. (11)
■A committee on nominations. (11)
■A committee on arrangements. (5)
.A medico-legal committee. (3)
.A committee on field activities. (7)
.A committee to receive resignations and to fill va-
cancies. (11)
.A committee on constitution and by-laws. (3)
A committee on finance. (3)
and such other committees as may be necessary.
Such committees shall be selected by the House
of Delegates unless otherwise provided.
Sec. 2. The Committee on Scientific Work shall
consist of three members: the President, Secretary,
and Treasurer, of which committee the President
shall be chairman, and shall determine the character
and scope of the scientific proceedings of the So-
ciety for each session, subject to the instructions of
the House of Delegates, or of the Society, or to the
provisions of the Constitution and By-Laws. Thirty
daj"s previous to each Annual Session it shall prepare
and issue a program announcing the order in wdiich
papers, discussions, and other business shall be pre-
sented, which shall be adhered to by the Society as
nearly as practicable.
Sec. 3. The Committee on Public Policy and Leg-
islation shall consist of three members and the
President and Secretary. Under the direction of the
House of Delegates, it shall represent the Society in
securing and enforcing legislation in the interest of
public health and scientific medicine. It shall keep
in touch with professional and public opinion, shall
endeavor to shape legislation so as to secure the best
results for the w'hole people, and shall utilize every
organized influence of the profession to promote the
general influence on local, state, and national affairs,
and elections. Its work shall be done with the dignity
becoming a great profession and with that wisdom
which will make effective its power and influence. It
shall have authority to be heard before the entire So-
ciety upon questions of great concern, at such time
as may be arranged during the Annual Session.
Sec. 4. The Committee on Publication shall con
sist of three members, of which the Editor shall be
one and chairman, and shall have referred to it all
reports on scientific subjects and all scientific papers
and discussions heard before the Society. It shall
be empowered to curtail or abstract papers and dis-
cussions, and any paper referred to it which may not
be suitable for publication in the Journal may be re-
turned to the author. All papers read before the
Society shall be the property of the Society.
VoL. XII, No. 11]
Journal of Iowa State Medical Society
473
Sec. 5. The Committee on Necrology shall con-
sist of all the members of the Council, who shall
prepare for each session suitable biographical no-
tices of deceased members.
Sec. 6. The Committee on Nominations shall be
appointed and perform its duties in accordance with
the provisions of Chapter V, Section 2 of these By-
Laws.
Sec. 7. The Committee on Arrangements shall
consist of the committee on scientific work and two
members elected by the component society in the
territory in which the Annual Session is to be held.
It shall, by committees of its own selection, provide
suitable accommodations for the meeting places of
the Society, of the House of Delegates, and of
their respective committees, and shall have general
charge of all the arrangements. Its chairman shall
report an outline of the arrangements to the Secre-
tary for publication in the program, and shall make
additional announcements during the session as oc-
casion may require.
Sec. 8. The Medico-legal Committee shall consist
of three members, all of whom shall serve without
pay. The term of servdce of each member shall be
three years, provided that in the original organiza-
tion of this committee the service shall be grouped
by lot into three divisions with terms expiring in
one, two and three years respectively from July 1,
1907. On and after July 1, 1907, it shall be the duty
of the members of this committee, severally or col-
lectivel}', to investigate all claims of malpractice
against members, to adjust such claims in accordance
with equity where possible, and, if in their judgment
an adjustment is impossible, or the claim is unjust,
or the damage sought is excessive, to lend such help,
aid, and council as they may deem proper; but they
shall not pay, or obligate the Society to pay, a judg-
ment against any member; nor shall they pay or ob-
ligate the Society to pay for legal counsel not author-
ized by the medico-legal committee. This shall not
apply to the cost of transcribing evidence in appealed
cases.
They shall effect such organization as they see fit,
and adopt rules for their guidance, and for the guid-
ance of members of the State Society in medico-legal
matters. They shall be empowered to contract with
such agents (attorney or other) as they may deem
necessary. They shall have charge of the medical
defense fund, which fund shall be secured as follows:
Each member of the State Society shall be assessed
$2.00 a year for this fund alone. This assessment
shall be paid along with the other state dues, and
through the same channels, and shall be kept in the
treasury of the Society. All bills for medico-legal
defense, after approval by the committee and the
Board of Trustees, shall be subject to warrants drawn
in the prescribed manner.
Sec. 9. The Committee on Field Activities shall
consist of seven members, all of whom, with the ex-
ception of two, shall be members in good standing
in the Iowa State Medical Society.
In the manner of selection of members, the Presi-
dent-elect shall be an ex-officio member from his
election until his inauguration as President; two shall
be nominated and elected by the Council; one to be
chosen by the Iowa State Board of Health; one, by
the faculty of the State University of Iowa College
of Medicine (both of whom shall be members in good
standing of the Iowa State Medical Society) ; one, by
the Executive Committee of The Iowa Tuberculosis
Association; one, by the Executive Committee of the
Iowa Conference of Social Work. (The last two
named may be chosen by their respective organiza-
tions for their fitness to represent the specifically
declared purposes of the organization.)
With the exception of the President-Elect, the
members of this committee shall be elected for two
years. (Those elected by the Council to cast lots for
the short term so that one of the two will be elected
at each annual meeting after 1922.)
The committee shall organize after the usual man-
ner: a chairman and secretary shall be elected; the
Secretary of the Iowa State Medical Society shall
be made Advisory Secretary of the Field Activities
Committee.
It shall be the function of this committee to col-
laborate with the Council as a body and with its
members in the formulation and carrying out of the
programs in their respective districts. It shall be the
special agency through which the State Medical So-
ciety and other agencies concerned with related ac-
tivities may establish sustained working relations,
formulate joint programs, and promote interest and
activity in lines calculated to increase the adequacy,
efficiency, and equality of distribution of applied
medical science throughout the State of Iowa.
The committee shall be empowered to employ such
help as it deems necessary within the limit of the
aggregate appropriation approved by the Board of
Trustees and House of Delegates of the State So-
ciety; to enter into such working agreements with
associated agencies as it may deem wise and proper;
to recruit volunteer speakers’ bureau and to pay the*
actual expenses of such speakers; to defray also the
actual expenses of members of the committee that
are incurred in performance of duties connected
therewith, subject to the same rules and restrictions
that apply to the Board of Trustees. All bills for the
expenditure of the appropriation shall be subject to
the approval of the Board of Trustees of the Iowa
State Medical Society, after which warrants for pay-
ment shall be made according to the provisions of the
By-Laws of the Iowa State Medical Society. The com,-
mittee shall not incur obligations beyond the provi-
sions of the appropriations placed at its disposal by
the House of Delegates, but this shall not prohibit
expenditure of funds that may be derived otherwise
than through said appropriations.
The committee may make rules governing the con-
duct of its affairs provided such do not conflict with
474
Journal of Iowa State Medical Society
[November, 1922
the Constitution and By-Laws of the Iowa State
Medical Societ}’, and shall have power to appoint sub-
committees and to invite the (non-voting) partici-
pation of persons as advisory members of the com-
mittee. In the event of absence or disability of the
representative member from either the low'a Tuber-
culosis Association or the State Conference of Social
Work, the president of such organizations may act in
his stead.
Sec. 10. The Committee to Receive and Act upon
Resignations and to Fill Vacancies shall consist of all
of the members of the Council, whose duty it shall
be to receive and act upon all resignations presented
between the Annual Sessions, and to fill by appoint-
ment, vacancies by reason of any cause whatsoever
w'hich may occur between the Annual Sessions, and
which are not otherwise provided for.
Sec. 11. The Committee on Constitution and By-
Laws shall consist of three members. It shall be the
duty of the committee to propose such amendments
to the Constitution and By-Laws as is deemed wise
and judicious, and to bring before the House of Dele-
gates such amendments as it, or other members of
the Society, -may care to present for consideration.
Sec. 12. The Committee on Finance shall consist
of three members, whose duty it shall be to audit the
books of the Society and to make a report of its
findings to the House of Delegates.
CHAPTER IX
Assessments and Expenditures
Section 1. An assesment of five dollars per capita
on the membership of the component societies is
hereby made the annual dues of this Society. The
Secretary of each county society shall forward its
assessments together with its roster of all officers
and members, list of delegates and list of non-af-
filiated physicians of the county, to the Secretary of
this Society on or before January 1st prior to each
Annual Session.
• Sec. 2. Any county society which fails to pay its
assessment, or make the reports required, on or be-
fore February 1st, shall be held as suspended, and
none of its members or delegates shall be permitted
to participate in any of the business or proceedings
of the Society, or of the House of Delegates, until
such requirements have been met.
Sec. 3. All motions or resolutions appropriating
money shall specify a definite amount, or so much
thereof as may be necessary for the purpose indi-
cated, and must be approved by the Board of Trus-
tees before being presented for final action to the
House of Delegates.
Sec. 4. The necessary expenses of conducting the
business of this Society during the interval between
the Annual Sessions, on approval by the Trustees,
shall be paid by the Treasurer on a written order of
the Secretary countersigned by the President, and a
report of said expenses and expenditures shall be
made, by the Secretary to the House of Delegates, at
the annual meeting.
CHAPTER X
Rules of Conduct
The principles set forth in the code of ethics of
the American Medical Association shall govern the
conduct of members in their relations to each other
and to the public.
CHAPTER XI
Rules of Order
The deliberations of this Society shall be governed
by parliamentary usage as contained in Robert’s
Rules of Order, unless otherwise determined by a
vote of its respective bodies.
CHAPTER XII
County Societies
Section 1. All county societies now in affiliation
with the State Society or those that may hereafter
be organized in this state which have adopted prin-
ciples of organization not in conflict with this Con-
stitution and By-Laws, shall, upon application to the
House of Delegates, receive a charter from, and be-
come a component part of, this Society.
Sec. 2. As rapidly as can be done after the adop-
tion of this Constitution and By-Laws, a medical
society shall be organized in every county in the
state in which no component society exists, and
charters shall be issued thereto.
Sec. 3. Charters shall be issued only upon ap-
proval of the House of Delegates and shall be
signed by the President and Secretary of this So-
ciety. The House of Delegates shall have authority
to revoke the charter of any component county so-
ciety whose actions are in conflict with the letter or
spirit of this Constitution and By-Laws.
Sec. 4. Only one component medical society shall
be chartered in any county. Where more than one
county society exists, friendly overtures and con-
cessions shall be made, with the aid of the Coun-
cilor for the district if necesary, and all of the mem-
bers brought into one organization. In case of fail-
ure to unite, an appeal may be made to the Council
which shall decide what action shall be taken.
Sec. 5. Each county society shall judge of the
qualifications of its own members, but as such so-
cieties are the only portals to this Society and to the
American Medical Association, every reputable and
legally registered physician in Iowa, who is practicing
or will agree to practice non-sectarian medicine, shall
be entitled to membership. Before a charter is issued
to any county society full and ample notice and op
VoL. XII, Xo. Ill
Journal of Iowa State Medical Society
475
portunity shall be given to every such physician in
the county to become a member.
Sec. 6. Any physician who may feel aggrieved by
the action of the society of his county in refusing
him membership, or in suspending or expelling him,
shall have the right of appeal to the Council and to
the House of Delegates.
Sec. 7. In hearing appeals, the Council may admit
oral or written evidence as in its judgment will best
and most fairly present the facts, but in case of ev-
ery appeal, both as a Board and as individual Coun-
cilors in district and county work, efforts at con-
ciliation and compromise shall precede all such
hearings.
Sec. 8. When a member in good standing in a
component society moves to another county in this
state, his name, upon request, shall be transferred
without cost to the roster of the county society into
whose jurisdiction he moves.
Sec. 9. A physician living near a county line may
hold his membership in that county society most
convenient for him to attend, provided no objection
is made by the society in whose jurisdiction he re-
sides.
Sec. 10. Each county society shall have general
direction of the affairs of the profession in the
county, and its influence shall be constantly exerted
for bettering the scientific, moral, and material con-
dition of every physician in the county; and system-
atic efforts shall be made by each member, and by
the Society as a whole, to increase the rnembership
until it embraces every qualified physician in the
county.
Sec. 11. At some meeting in advance of the An-
nual Session of this Society, each county society
shall elect a delegate to represent it in the House of
Delegates of this Society in the proportion of one
delegate for each fifty members, and one for each
major fraction thereof, but each county society hold-
ing a charter from this Society, which has made its
annual report, and paid the assessment as provided
in this Constitution and By-Laws, shall be entitled to
one delegate.
Sec. 12. The Secretary of each county society
shall keep a roster of its members, and a list of non-
affiliated registered physicians of the county, in
which shall be shown the full name, address, college,
and date of graduation, date of license to practice in
this, state, and such other information as may be
deemed necessary. He shall furnish an official re-
port containing such information upon blanks sup-
plied him for the purpose, to the Secretary of this
Society, on or before February 1st, of each year.
In keeping such roster, the Secretary shall note any
change in the personnel of the profession by death,
or by removal, to or from the county, and in making
his annual report he shall be certain to account for
every physician who has lived in the county during
the year.
CHAPTER XIII
Amendments
These By-Laws may be amended at any Annual
Session by a majority vote of all the delegates pres-
ent at that session, after the amendments have laid
upon the table for one day.
CHAPTER XIV
The Journal
Section 1. The House of Delegates shall estab-
lish an official journal of the Iowa State Medical
Society, which shall be called The Journal of the
Iowa State Medical Society.
Sec. 2. The Journal shall be published monthly,
and mailed not later than the 15th of the month, and
it shall contain the papers and proceedings of the
annual meeting and such other matter as is of in-
terest to the members.
Sec. 3. The Journal shall contain not less than
forty-eight pages per issue, and editorials shall be
given a prominent part.
Sec. 4. An Editor shall be elected by the House
of Delegates for a period of three years, his salary
shall be fixed by the Trustees, and shall be paid
quarterly, and shall include all office assistance and
rent. Salaries and expenses shall be paid by the
Treasurer on a written order of the Secretary coun-
ter-signed by the President when authorized by the
Board of Trustees.
Sec. 5. An allowance shall be made for necessary
office supplies and postage.
Sec. 6. The printing and mailing of the Journal
shall be let by the Trustees on yearly contract con-
forming to required specifications, and expenses ac-
cruing therefrom shall be paid quarterly by the
Treasurer on a written order of the Secretary coun-
ter-signed by the President when authorized by the
Board of Trustees.
Sec. 7. The advertising policy shall be that of the
Journal of the American Medical Association.
Sec. 8. The committee on publication shall have
oversight of the publication of the Journal subject
to the order of the House of Delegates. The Trus-
tees shall audit the books of the Editor and author-
ize any contract which may be necessary.
Sec. 9. The committee on publication shall have
editorial control of the Journal, and shall provide
for and superintend the publication and distribution
of all proceedings, transactions, and memoirs of the
Society.
Sec. 10. All reports on scientific subjects and ail
scientific discussions and papers heard before the
Society shall be referred to the Journal for publica-
tion. The Editor, with the consent of the majority
of the committee on publication, may curtail or ab-
stract papers not considered suitable for publication.
Sec. 11. All monies received by the Editor shall
be turned over to the Treasurer at the end of each
month.
476
Journal of Iowa State Medical Society
[November, 1922
BOOK REVIEWS
DISEASES OF THE DIGESTIVE ORGANS
WITH SPECIAL REFERENCE TO THEIR
DIAGNOSIS AND TREATMENT
By Charles D. Aaron, Sc. D., M. D., F. A.
C. P., Professor of Gastroenterology and
Dietetics in the Detroit College of Medicine
and Surgery; Consulting Gastroenterologist
to Harper Hospital. Third Edition, Thor-
oughly Revised. Illustrated with 164 En-
gravings— 48 Roentgen-organs and 13 Col-
ored Plated. Lea and Febiger, Philadelphia,
1922. Price $10.00.
The rapid development and great interest in dis-
eases of the digestive organs has led to a vast litera-
ture on the subject, especially in roentgenology, as
a means of diagnosis. Fortunately from time to time
books appear from men of large experience and great
skill in the use of this means of diagnosis and also
in treatment; who also give at least a reasonable val-
uation on what is placed before us. No one has suc-
ceeded better than Professor Aaron in eliminating
the elements of error in diagnosis which are sure to
creep in, so difficult is the subject. The three edi-
tions of this important work appearing in rather
rapid succession indicates the activity of this worker
in his particular line. There are numerous illustra-
tions of a most helpful character, showing the in-
terest of the publishers in presenting a book having
for its purpose aiding the medical practitioner in
reaching a fair diagnosis. The treatment of the
numerous forms of diseases and conditions of the
digestive system is presented in a logical relation
with the disease considered.
When we consider the 904 pages devoted to dis-
eases of the digestive organs including physiology,
chemistry, pathology, symptomatology, diagnosis and
treatment we realize the immense amount of work
involved and the immense importance given to dis-
ease of the digestive system.
THE PLACE OF VERSION IN OBSTETRICS
By Irving W. Potter, M.D., F.A.C.S., Buf-
falo. Obstetrician-in-Chief, Deaconess Hos-
pital and St. Mary’s Maternity Hospital;
Attending Obstetrician, City Hospital, Etc.,
with 42 Illustrations. C. V. Mosby Co., St.
Louis, 1922. Price $5.00.
The author from a large personal experience in
obstetric practice has arrived at the conclusion that
version will aid materially in eliminating the second
stage of labor and in relieving the women of much
of the pains and agonies of childbirth with no in-
crease of fatal mortality. This is contrary to the
general experience of obstetricians who have looked
upon this procedure with apprehension so far as the
fetus is concerned and have reserved it for special
conditions. Considerable space is given to the early
history of version and of version in the nineteenth
century. After presenting a very interesting history
of version before the introduction of anesthesia, and
the evolution during the nineteenth century, and after
the use of anesthetics we came to version of the
present day. The author states that at the opening
of the twentieth century “version was looked upon
as an emergency operation to be employed only when
the forceps had failed, or was for some reason ob-
viously impractical.” Then we have the views of
obstetrical writers generally in line with the intro-
ductory statement. Commencing with chapter four,
the author presents his own technique of version.
This is described in much detail and profusely illus-
trated. Chapter five considers criticisms and an-
swers. Five years ago he presented his method of
podalic version before the American Association of
Obstetricians and Gynecologists, which met with
much adverse criticism. This criticism has led the
author to review the subject in relation to his conten-
tion. Chapter six is devoted to a discussion of the
indications and advantages of version. Chapter
seven. Conclusions. The author presents two series
of versions, one of 500 cases with no maternal deaths
and 57 stillbirths, also a second series of 200 cases
with no maternal deaths and with 16 stillbirths.
Giving a total of 700 versions with no maternal
deaths and 73 stillbirths from numerous causes not
attributable to the procedure. Certainly the book
is a valuable contribution to obstetrical practice.
OPIATE ADDICTION— ITS HANDLING AND
TREATMENT
By Edward Huntington Williams, M.D.,
Formerly Associate Professor of Pathology,
State University of Iowa. Special Lecturer
on Criminology and Mental Hygiene, State
University of California, Etc. The Macmil-
lan Company, New York, 1922. Price $1.75.
Dr. Williams has taken an interest in questions re-
lating to alcohol and narcotics from the standpoint
of pathology. He has undertaken to show that much
of the legislation touching the control of opium and
alcohol has failed because the laws have not taken
into account physical and mental conditions which
are often the underlying causes of addiction. It is
difficult to make laws that will reach all the excep-
tions that may come up in the interpretations of the
general purpose of the legislation.
Dr. Williams in the volume on Opiate Addiction
has presented a reasonable argument in support of
the antinarcotic laws and an interpretation of their
application. It would be quite impossible to obey the
absolute letter of the law without great hardship to
many, and if the legislation is measured from the
standpoint that narcotic addiction is a criminal act
the legislation would fail. Drug addiction often is
the result of conditions for which the individual is
not responsible, from mental defects which legisla-
tion cannot control. There is a large class of addicts
who cultivate the habit in a criminal sense. These
VoL. XII, No. 11]
Journal of Iowa State Medical Society
477
conditions are discussed in the introductory chapter.
It appears that with a diligent enforcement of the
law during a period of five years there have been a
considerable increase in the amount of opium con-
sumed. There has been no doubt a decrease in the
use of opium for legitimate purposes but a marked
increase in its unlawful use. The author states;
“From a medical viewpoint the law has the funda-
mental defect of not giving sufficient consideration
to the underlying cause of opium addiction” and
proceeds to enlarge on this point.
Opiate Addiction Chapter One. Opening state-
ment; “The term opiate addiction implies a definite
pathological condition.” This chapter sets forth the
opinion generally held by the medical profession and
should be carefully considered by those who have the
enforcement of the law in hand.
In Chapter two the treatment of opium addiction
is considered from the standpoint of gradual reduc-
tion. Chapter four considers the treatment from the
standpoint of Rapid Withdrawal. In Chapter three
is presented a number of useful hypnotics which may
be used in treating the insomnia which accompanies
the withdrawal of opium and in Chapter six Com-
ments and Observations. The reader of this book
will gain many useful points on this very important
subject. It is beginning to be understood that opium
and alcohol addiction cannot be controled by legis-
lation but can and should be regulated by law. The
question of opiate addiction should be studied from
a medical point of view and not determined by sen-
timent.
THE MANAGEMENT OF THE SICK INFANT
By Langley Porter, B.S., M.D., M.R.C.S.
(Eng.), J.R.C.P. (Lond.). Professor of Clin-
ical Pediatrics, University of California Med-
ical School, Visiting Physician, San Fran-
cisco Children’s Hospital, and William E.
Carter, M.D., Assistant in Pediatrics and
Chief of Out Patient Department University
Medical School, Etc.; 654 Pages with 54 Il-
lustrations. C. V. Mosby Co., St. Louis, 1922.
Price $7.50.
The deep interest shown in many directions in the
management and treatment of children’s diseases has
stimulated the production of numerous books on
different features of child welfare and new studies
in children’s diseases. The particular feature of this
book is the consideration given to the peculiarities
of disease as it occurs in infants. Every practitioner
recognizes the difficulties of managing sick infants
and so much has this been recognized, that in the
larger centers of population men of peculiar adapta-
bility are devoting themselves to this special branch
of medicine. Among country practitioners the doc-
tor must from the necessities of his position act as
a specialist in many directions. In this book he will
find helpful aid in working out diagnosis and treat-
ment, and none the less, the practitioner in larger
centers where special practice is pos.sible. In con-
sidering this book as a whole, it will be found an
e.xhaustive treatise on the management of sick in-
fants and to fill a welcome place in a doctor’s library.
HAVFEVER AND ASTHMA, CARE, PREVEN-
TION AND TREATMENT
By William Scheppegrell, A.M., M.D.,
President, American Hayfever Association;
Ex-President American Academy of Oph-
thalmology and Otolaryngology; Chief of
Hayfever Clinic, Charity Hospital, New Or-
leans. Illustrated with 107 Engravings and
1 Colored Plate. Lea and Febiger, Philadel-
phia, Price $2.75.
Hayfever has so much to do with human happiness
that a study of the causes of hayfever and its asso-
ciated relationship to asthma promises to add so
much to the comfort and happiness of the race that
we should welcome the investigations of patient
workers in this field.
The amount of ignorance and superstition in rela-
tion to what causes hayfever is very great. Dr.
Scheppegrell for a series of years has endeavored to
show the public the nature of the agent which has
distressed many people and caused them to flee
from their homes to secure rest and comfort. It
was not until 1819 that hayfever was considered a
disease and not until 1873 was it known to be caused
by a pollen, and innocent plants were accused. It
was important that the guilty ones should be dis-
covered, and this has been the work of Dr. Scheppe-
grell, who has embodied his studies and investiga-
tions in a volume of 274 pages. A short history of
hayfever is followed by discussion of the pollen re-
sponsible, chemical composition and conviction.
Then comes a consideration of the type of hayfever
plants and their distribution. With chapter seven
we have a short description of the anatomy and phy-
siology of the nose. In chapter eight the symptoms,
diagnosis, susceptibility and atypical forms are pre-
sented. It is also shown that the disease is not of
microbic origin. In chapter nine, the exciting and
predisposing causes are pointed out, the onset of at-
tack, hereditary influences and the relation of hay-
fever and asthma. Following is an interesting dis-
cussion of hayfever seasons for different states, oc-
cupations, exposure, percentages. Influence of sex,
age, race, etc. Chapter twelve considers hayfever
pollens and their reactions, as spring and fall hay-
fever. Potential areas, atmospheric conditions, test-
ing the wind-pollination of hayfever plants and other
important facts in relation to this disease which the
profession and the public should know as a means
of prevention.
The remaining portion of the book is devoted to
the treatment of hayfever. Being due to a pollen as
already stated the important thing is to avoid or
destroy the responsible plant. There appears to be
478
Journal of Iowa State Medical Society
[November, 1922
no specific remedy unless it be by immunization bj"
preparing a vaccine. The result of this treatment has
not been fully determined but seems to be of consid-
erable promise. The preparation of vaccines is de-
scribed and the methods of administration pointed
out. The wide prevalence of the disease suggests
the careful study of Dr. Scheppegrell by the profes-
sion and the victims of the disease.
MANUAL OF CLINICAL LABORATORY
METHODS
By Clyde Lottridge Cummer, Ph.B., M.D.
Cloth. Pp. 484, with 136 Engravings and 8
Plates. New York and Philadelphia. Lea
& Febiger, 1922.
The publication of this volume is amply justified
by the fact that new laboratory methods are con-
stantly being invented and that cliidcal experience,
from time to time, places a truer and truer evaluation
upon older methods. Cummer’s work leaves little
to be desired. The binding is solid and strong, the
paper is good and the type is large and readable.
The text is well written and accurate and the illus-
trations are well chosen. A number of them are
original. The book deals comprehensively with the
new'er methods of blood chemistry and serology. In
a word the book is one of the best of its kind.
D. J. Glomset.
SYMPTOMS OF VISCERAL DISEASE
A Study of the Vegetive Nervous System
in its Relationship to Clinical Medicine. By
Francis Marion Pottinger, A.M., ^LD., L.
L.D., F.A.C.P., Medical Director, Pottinger
Sanatorium. For Diseases of the Lungs and
Throat. Second Edition with 86 Text Illus-
trations and 10 Color Plates. C. Mosby
Co., St. Louis, 1922. Price $5.50.
The second edition of this important work is be-
fore us. In the preface w-e note the satisfaction of
the author in the early exhaustion of the first edition
as an expression of the interest of the profession in
this manner of presenting important facts and the-
ories in the science of medicine.
The book begins with an introductory chapter on
the Evolution of Medicine. The purpose of the
author is to bring out the influence of the nervous
system in diseases of the viscera and for this purpose
begins the second chapter by classifying symptoms
of disease from the standpoint of the autonomic ner-
vous system. Dr. Pottinger in chapter five, brings
out in his discussion wdiat he regards as the most
important, the “vicerogenic reflex” and from this
point on to chapter nine the theory is amplified in a
very interesting and convincing way. The discussion
is somewhat difficult but well w'orth struggling wdth.
Chapter nine, part two, is an introduction to the
viscerogenic reflex relating to the vegetive nerves
beginning with the digestive tract, and continuing
with the liver, gall-bladder; the diaphragm; the
bronchi and lungs and the pleura. Then comes the
heart and blood-vessels; the larynx; the eye; the
lachrymal glands; the urogenital tract; the endocrin
glands and concluding in part three, with the vegetive
nervous sj^stem.
THE MEDICAL CLINICS OF NORTH
AMERICA
Volume Five, Number Five, March, 1922.
By Boston Internists. Octavo of 335 Pages,
with 62 Illustrations. Price Per Clinic Year
Paper $12.00, Cloth $16.00 Net. W. B.
Saunders Company.
The first paper of this number is by Professor
Henry A. Christian of Peter Bent Brigham Hospital
under the title of Digitalis Effects in Chronic Car-
diac Cases. Following this important paper is one
by Dr. William H. Robey entitled Angina Pectoris
with and without Cardiac Signs. Dr. Elliot P. Joslin
considers Deaths Eollowing Sudden Changes in Diet,
and Dr. John Lovett Morse, Chronic Indigestion in
Earh- Childhood. Dr. George R. Minot presents an
interesting analysis of Blood Loss Due to Patho-
logic Hemorrhage. The Study of Myxedema with
Observations of the Basal Metabolism is the subject
of a paper by Dr. Cyrus C. Sturgis. Acute Rheu-
matic Myocarditis by Dr. Joseph H. Pratt and Car-
diovascular Syphilis by Dr. William D. Reid are two
papers of much interest from a physician’s point of
view. Another paper of this interesting collection
is by Drs. Louis E. A'iko and Paul D. White relating
to Observations on Important Disorders of the Heart
Beat.
We have before us the May or Chicago number of
the Medical Clinics of North America including the
index of this important volume, of 1817 pages. In
this number may be found twenty-one papers by well
known Chicago internists. Abdominal Reflex Dis-
orders by Dr. Arthur R. Elliot. This is a short pa-
per, but of much interest, touching the influence of
disturbing emotional states on the autonomic ner-
vous system and the secondary effects thereof. Fre-
quency of abdominal disturbance, particularly of the
digestive type having a neurotic basis, followed by a
Clinic on Pernicious Anemia by Dr. Charles Spencer
W'illiamson, and a Clinic by Dr. C. G. Brulee on In-
fantile Eczema. Dr. Isaac A. Abt presents a Case of
Carbon ilono.xide Poisoning in a Child. The very
interesting subject of the Diagnosis of the Gastric
Neurosis is presented by Dr. Joseph C. Friedman
It is a subject never to be overlooked. In a series
of cases by Dr. Charles L. Mix is a discussion of Ad-
hesions Following Cholecystectomy, chiefl}^ Periduo-
denal.
Jfournal of tjje
Jlotua ^tate j$lei)ital ^ocietp
VoL, XII Des Moines, Iowa, December 15, 1922 No. 12
ORATION ON MEDICINE*
B. L. Eiker, M.D., Leon
Mr. President, Ladies and Gentlemen:
The oration on medicine, delivered before a
scientific body like this one, is supposed to come
from someone whose training, education and op-
portunities are such as to place him in direct
touch with the first whisperings of advanced
medical science. He is supposed to review the
past and emphasize the improved and established
methods for the diagnosis and treatment of dis
ease. He is supposed also to look into the unex-
plored fields for the year to come, and point out
the way that seems best to blaze trails toward
desired medical achievements. On this occasion
we desire to depart from that time-honored cus-
tom. Not because we cherish anj^ disrespect for
the custom itself, but because there is now arising
in the dim distance other problems worthy of our
most earnest consideration. Problems that at
this time are so minor in appearance that their
importance seems to be overlooked. Problems
that are fundamental to the welfare, not alone of
the medical profession, but of the entire nation.
Our purpose at this time is to present to you a
few of these problems as they appear to the gen-
eral country practitioner.
The practice of medicine is a privilege granted
to certain individuals who have complied with
certain requirements, it is not a right mysteriou.sly
achieved by the individual and held as his own
and exclusive accomplishment. It has for its
beginning and for its end the welfare of the indi-
vidual patient ; and from this standpoint and this
alone must all laws, rules and regulations pertain-
ing to disease and its prevention be considered.
Erom the babe in its helplessness to the potentate
with unlimited power, from the army of school
children to the powerful army of our nation’s
defense, the medical profession is indispensable.
It follows, therefore, that in order to properly
care for future generations, surrounded as they
will be with all the intricacies of modern civiliza-
^Presented before the Seventy-First Annual Session. Iowa State
Medical Society, Des Moines, Iowa, ^Iay 10, 11, 12, 1922.
tion, the medical man to take your place and mine
must be a man of more than ordinary ability, en-
dowed by nature with those attributes calculated
to inspire confidence and fit him for leadership.
To these natural attributes must be added that
long laborious process of education and training
which develops the mind of the individual so that
he may accurately determine his relations to his
surroundings, and to develop the skilled hand to
execute the mind’s command. Individuals cap-
able of properly caring for the health of a com-
munity or nation are not found in every home,
they cannot be educated in the twinkling of an
eye, neither do they receive their attainments
from some hidden and unseen power. “Men do
not gather grapes from thorns nor figs from
thistles’’ today any more than they did centuries
ago.
To take up a burden of whatever nature im-
plies that there must be a place and there must
be a time where that burden will be laid down.
There is a place where responsibility begins and
a place where responsibility ends. We have no
moral right to pretend to treat the sick unless we
have that degree of training and skill which en-
ables us to properly diagnose and treat disease as
measured by the generation and day in which we
live. On the other hand the individual, commun-
ity, or country has no moral right to demand of
the medical man the best results unless that same
individual, community or country contribute their
share towards surrounding themselves with such
environment as to enable the medical man to
reach his highe.st degree of attainment and ac-
complishment. In other words, there is a place
where the responsibility of the medical man
ceases and the responsibility of the community be
gins.
Aside from their scholastic attainments, little
attention has been paid in times past to the kind
of young men and young women permitted to
study medicine. As a result of this slipshod
method we have our neurotic physicians, follow-
ing a step further we have our physicians who
are dope fiends and going a .step farther our doc-
tors with reprehensible moral idiosincracies ; all
480
Journal of Iowa State Medical Society
of which lower the standard of the medical pro-
fession and injure its usefulness and influence in
a community. It is universally admitted by those
who think that there is no higher calling than that
of a medical man. Does it then not follow that
our medical schools should allow none to enter its
doors except those who are physically sound;
mentally capable, and morally fit? If we were
more particular about the class of men and
women permitted to study medicine our profes-
sion would be held in higher regard by the laity.
To be eligible to enter a reputable and recog-
nized medical school of the present day one must
have had a high school education, and at least two
years in liberal arts. In addition to this he must
take a four years course in medicine and supple-
ment this with one year’s work in a hospital. If
you have a boy or girl who desires to become a
doctor of medicine they will be required to follow
out this long, expensive and laborious course. At
the present time medical men are dying off faster
than they are being educated and graduated. Al-
ready some sections of the United States are be-
ginning to feel this lack of medical men and very
naturally they inquire into the cause.
The average human mind loves notoriety and
longs to be the first to discover the conflagration
and call out the fire department. Many investi-
gations of inquiries are carried on hy well mean-*
ing individuals but individuals who are sorely
handicapped in their arduous task by active
tongues and equally inactive minds. The result
of investigations being carried on by this class of
individuals can be easily guessed. In the present
investigation relative to the dearth of medical men
the cause was immediately located and a lemedy
forthwith suggested. The cause given was too rigid
entrance requirements by our medical schools, and
forthwith a lamentation went up for a return to
the good old fashioned family doctor with his
primitive methods, and his poor results, which
time and lapse of memory have magnified into
Christ-like achievements. Far from me to pluck
one laurel from the crown of my predecessors,
and I have no respect for the man who will do so.
They filled their niche in life and did it well in
their day and generation. But this is a different
age compared to the one in which they lived.
'I'heir methods of treating disease and caring for
patients, if they were put in use today, would be
as antiquated when compared with our methods
as their means of transportation at that time
would be if compared with our present day
method of transit. The old family doctor is ra])-
idly ]:>assing, jiassing from the earth never more
to return and even those who mourn his going
[December, 1922
would not themselves employ him if he were here
today.
To the man who insists on lowering the medical
standards of today, bear this message; “It re-
quires years of persistent, patient toil to rear the
.sturdy oak tree, a tree that can withstand the
storms and caprices of the w'eather; but a pump-
kin can be matured in three months.” It takes
time to develop the mind to that point of stability
where it can act with accuracy when the storm-
tossed love of zealous friends are clutching fran-
tically at every ray of hope that offers the slight
est promise of evading death. To lower the en-
trance requirements and bring down the standard
of American medical schools would be as much
of an insult to coming generations as it would
have been to have lowered the stars and stripes of
America to the imperial power that sought its
anihilation.
After having selected your material from those
young men and women of the highest physical,
mental and moral type, after having educated
them in the best schools of America, you have
your product ready for the market. Where will
you market this finished product, where will you
have this young man or young woman locate?
There does not live in this great commonwealth
of ours a man or woman capable of educating a
boy or girl for the medical profession of the pres-
ent day that would think of locating that boy or
girl at the country crossroads. And if a man or
woman has graduated from one of the present
day accredited medical schools of America and is
then content to locate and stay at the country
crossroads town, there must be something rad-
ically wrong with the mental attitude of that indi-
vidual. Having spent five years of his life with
medical men and surrounded as he has been by
the highest type of medical environment, he will
find himself an utter misfit in any small town
that has no hospital and nothing to commend it
e.xcept a rich surrounding country. A farmer
cannot raise his best corn on a race track, neither
can a race horse make his fastest time in a corn
field. The people of this country if they expecc
the best medical aid must awaken to their re-
siionsibility and to the necessity of having well
equipped hospitals for the care of those unfortun-
ate members of their family that may need med-
ical care.
In looking over the events of history one can-
not help but be impressed with the fact that little
progress has ever been made by the human race
until they had first sacrificed many human lives
trying out some antiquated and obsolete method.
So it will be with the hospitalization of the United
VOL.XII, No. 12]
Journal of Iowa State Medical Society
481
States. When the people and medical profession
finally awaken to the fact that the old family
doctor is a thing of the past, that educated men
will not be content to spend their lives and the
lives of their families in the small country town
where gossip and talk offers the only means of
education ; when they finally awaken, then and
not till then can we expect hospitalization which
is an absolute necessity if we expect to increase
the efficiency of the man power of this country.
However, this will probably not be brought about
until such time as the people of the United States
in the name of personal liberty have sacrificed
hundreds of lives of all classes of people and
soaked their antiquated ideas with human blood
in a vain endeavor to bring back old time condi-
tions.
The average human being loves a funeral, he
hates progress. He fails to understand why he
cannot procrastinate and argue with a microbe of
disease the same as he can with his neighbor.
“Water seeks its level’’ and if you surround a
medical man with the environments heretofore
described he will of necessity retrograde, he can-
not do otherwise. In union there is strength, jn
segregation weakness ; medical men must be so
situated that they can easily and readily obtain the
upbuilding, uplifting and helpful influence of
each other if they are to render their greatest ef-
ficiency in this reconstructive program of our
civilization.
In conclusion I desire to summarize a few facts
as they appear to the general practitioner en-
gaged in country practice. The practice of med-
icine begins and ends with securing the best that
can be secured for the patient.
The utmost care should be exercised in select-
ing men and women for the study of medicine.
The highest standard of medical education
compatible with advanced medical science must
be maintained at all hazards.
The people at large must realize that part of
the responsibility for health conditions rests with
them.
Neither medical men nor laymen should waste
valuable time in lamentations over past history.
Turn your faces to the front. Rivet your eyes
upon the great possibilities of the medical future.
Remember that nothing can permanently endure
unless it rests upon an established, proven and
permanent foundation. Give no heed to the side
issues of “opathies” and “isms.” Give them re-
sponsibility, leave them alone and they will die
in their own excrement. But march straight to-
ward that goal of accomplishment, namely ; the
prevention of disease, the alleviation of human
suffering and the building up of the efficiency of
our country’s man power.
INJURIE.S TO THE SPINE NOT INVOLV-
ING THE CORD*
Oliver J. Fay, M.D., F.A.C.S., Des Moines
The discovery and development of the roentgen
ray cast a new light on many obscure medical
problems, and perhaps in no field was the illum-
ination of greater value than in the field of spinal
injuries. Fractures and dislocations involving the
cord had long been recognized by their clinical
symptoms, but where grave injury had been done
without cord involvement, and in all lesser in-
juries to the spine, definite diagnosis had been
almost impossible. A new impetus has also been
given to the study of these injuries by the enact-
ment of compensation laws. Determination of
the extent of disability and its probable duration
is at best a difficult problem, and the more ac-
curate study, which has been accordingly de-
manded, has done much to clarify our knowledge
of the lesser injuries to the back. And with this
better understanding has come a more adequate
therapy.
Crushing of the body of a vertebra is always to
be considered a serious injury because of the
danger of injury to the cord, yet such an injury
may occur and may go on to healing without
causing serious disability at any time. I have re-
cently had a striking illustration of the truth of
this statement. A young man while working at
the top of a twenty-five foot pole, received a bad
electric shock, and fell to the pavement, striking
on the buttocks. He had two electric burns of
the left hand and these he permitted to be dressed,
but he refused to await the development of the
x-rays which had been made, and instead was
driven overland in a Ford roadster to his home,
a distance of twenty-five miles. When I first
saw the patient some six weeks later, he com-
plained of inability to lift any considerable weight,
and of tiring easily. He was able to stoop about
half the normal distance, and to bend without
acute pain, but there was a prominence over the
second lumbar vertebra, and the x-ray revealed a
crushing injury of the body of this vertebra, and
a fracture of the transverse process on either side.
The patient was restive under any restraint, but
was supposed to remain quiet at his home. Five
‘Presented before the Seventy-First Annual Session, Iowa State
Medical Society, Des Moines, Iowa, May 10, 11, 12, 1922..
482
Journal of Iowa State Medical Society
[December, 1922
and a half months after the injury he was allowed
to take up light work at his own urgent request,
and a month and a half later, he insisted upon
returning to his accustomed work. The range
of motion is entirely normal, and the tissues move
freely over the callus.
It is evident that in a case of this sort, where
all symptoms of cord irritation or injury are lack-
ing, and where strong musculature renders the
elicitation of crepitus difficult, a diagnosis of
fracture of the \ertebra would be practically im-
possible without the aid of the x-ray. Yet with
such off-hand treatment as that accorded his in-
jury by this patient, secondaiy injury to the cord
is always possible, and without a definite diagno-
sis, the physician himself, finds it difficult to
steer a safe course between the Scylla of inade-
quate treatment, and the Charybdis of overtreat-
ment.
Fractures of spinous processes were unrecog-
nized in most cases before the employment of the
x-ray as a routine practice in all accidents in
which bony lesions are at all probable, and went
to swell the number of cases grouped under the
convenient head of traumatic lumbago. In part
the diagnosis depended upon the severity of the
trauma — if the accident suggested direct violence
of a formidable sort, the diagnosis might be frac
ture of a vertebra, while fracture of a spinous
process due to minor force passed as traumatic
lumbago. The subjective symptoms of pain and
localized tenderness vary in degree with the pa-
tient’s exaggerated or sluggish reaction to pain,
and the objective symptoms of crepitus and pal-
pation of a movable fragment are often lacking,
particularly when the fracture is incomplete, or
the patient has powerful musculature. In earl}-
cases, the x-ray may reveal a line of fracture or
the displaced fragment, while in later cases the
callus is seen, always granted that the plate is
clear, and that its interpreter is familiar with the
peculiarities of skiagraphs of this region.
Fractures of the transverse process when not
associated with injury to the body of the vertebra
are practically always due to indirect violence,
and the determining accident may be trivial or
severe. The symptoms are essentially those of
fracture of a spinous process, though crepitus
can rarely be elicited. Fractures of transverse
processes almost invariably involve lumbar verte-
brae, while the spinous processes most frequently
fractured are those of the thoracic vertebrae, oc-
casionally those of the cervical or lumbar verte-
brae. Pain on the whole is a more marked feature
of fractures of transverse than of spinous pro-
cesses. The pain may radiate to the anterior ab-
dominal wall, the extremities, the groin, the
coccyx, and in the absence of an x-ray, it has led
not only to the familiar diagnosis of lumbago, but
also to that of appendicitis.
Fracture of the arch is a connecting link be-
tween the lesser and the graver injuries of the
spine. Where the fracture is bi-lateral, as it
often is, displacement of the fragments sometimes
results in more or less grave injury to the cord,
and the injury then assumes something of the
rank of a fracture of the vertebral body. But
unilateral fracture of the arch is probably more
frequent than we surmise, since here even the
x-ray may fail to give us definite information.
Under sprains of the spine we group many
injury cases in which we are forced to reason
from an indefinite pathology to an indefinite
etiology or mechanism. In sprains, the radio-
graphic study of the spinal column is negative,
but following a fall upon the head or back, the
direct application of force by a blow, or even fol-
lowing the strain of forced lifting, we encounter
the symptoms made familiar by the so-called
sprains of other joints. (I am arbitrarilv ruling
out those cases in which there are more than
transient symptoms of cord injury). The path-
ology can only be surmised — overstretching and
torsion of ligaments, lacerations or contusions of
ligaments and capsules, for the mechanism of a
sprain is essentially that of an incomplete or
transient dislocation. Sprains, like dislocations,
are most common in the cervical region where
the range of motion is widest; they occasionally
occur in the lumbar, and are rarely met with in
the dorsal region.
The diagnosis of contusions of the vertebrae,
like the diagnosis of sprain, has an uncertain basis
in that the pathology can rarely be demonstrated,
and diagnosis is reached by a process of elimin-
ation. When, following a fall upon the head,
back or buttocks, there is pain on motion, as evi-
denced by muscular rigidity, and pain on pressure
over the given area ; when fracture of the verte-
brae has been ruled out, and the diagnosis sprain
is hardly adequate, we speak of contusions of the
vertebrae. While sprains are usually in the cer-
vical region, contusions of lumbar vertebrae are
most common, and bruises of the skin and mus-
cles are often associated with contusion of the
underlying bone. Sometimes the x-ray gives evi-
dence of a slight injury, some irregularity of the
margin of the body of the vertebra.
Traumatic spondylolisthesis is an unusual and
rarely recognized injury of the spine. As a result
VOL.XII, No. 12]
Journal of Iowa State Medical Society
483
of a fall or blow upon the head or shoulders in*
most cases, there is a forward dislocation of the
fifth lumbar vertebra. Kleinberg says that the
clinical evidence of this condition is found in
prominence of the sacrum; a palpable and often
visible hollow immediately above the sacrum ; pain
in the back and lower extremities ; weakness and
stiffness of the back; lordosis; forward bending
of the trunk; and tenderness of the lumbo-sacral
region. Immediate symptoms of the injury may be
less severe than those which develop subsequently.
The injured has sometimes continued at work for
a time. The pain and weakness in the back and legs
becomes more marked, and there is increasing de-
formity in the lumbar region. X-ray evidence
is not lacking, but skiagraphs of the region are
difficult of interpretation so that a definite diag-
nosis is probably only possible to the trained
roentgenologist.
The number of cases of so-called traumatic
lumbago decreases in direct I'atio to the care with
which the lesser injuries of the spine are classi-
fied according to the actual pathology. The term
as here used is applied only to those cases in
which following some sudden or unusual move-
ment, sudden severe pain in the back develops.
The x-ray is negative, and the very nature of the
accident makes actual injury to the vertebrae ex-
tremely improbable, so we assume that injury to
muscle or nerve fibres is responsible for the pain,
and for w'ant of a more specific terminology^ we
speak of traumatic lumbago. In industrial medi-
cine, the term is a peculiarly unfortunate one, for
in a majority of cases the incriminated accident
has been too slight to warrant the application of
the term “accident” i. e., there has been no un-
usual or excessive muscular effort required. The
onset of the pain in any case of so-called lumbago
is characteristically sudden so that the term “trau-
matic” should only be applied to those cases of
lumbago in which the onset of pain was imme-
diately preceded by some unusual exertion, such
as the lifting of an excessive weight, or by some
external violence. Kuth, in reporting a series of
208 cases of pain in the lower back, says that a
history^ of trauma was given in over 50 per cent
of the cases, w'hile on investigation it was found
to be a factor in only 18 per cent. Pain of osteo-
arthritic origin is often first noted following some
minor injury, or a supposed sprain of the back.
In a general way, fractures of the spinous or
transverse processes or of the arch should be ac-
corded the treatment given any fracture — immo-
bilization. Complete immobilization is probably
only attained when a body cast is supplemented
by' extension, and in these lesser fractures such
radical treatment would probably be productive
of more harm than good unless special indications
were j)resent. The application of a cast alone, or
even simple adhesive strapj)ing, together with rest
in bed, is usually sufficient. In the case of sprains
and contusions and even so-called traumatic lum-
bago, careful adhesive strapping and rest in bed
are again advised. Where fractures are inade-
quately treated, the disability due to pain on flex-
ion and rotation of the spine may be indefinitely
prolonged, and even in cases of injury without
demonstrable anatomical lesions, partial perma-
nent disability may' result where the primary
scoliosis, the result of involuntary muscular rigid-
ity, or of the patient’s voluntary attempt to as-
sume a comfortable position, may become per-
manent.
These lesser fractures should heal in approxi-
mately the same time required for union of any'
small bone. The patient should then be encour-
aged to take graduated exercise; hydrotherapy is
a useful though not an essential part of the after-
treatment. An ununited fragment or a large
callus may occasionally give rise to trouble, and
so necessitate operation, but even here the prog-
nosis is excellent and disability should not be pro-
longed beyond a few months.
Prognosis is notoriously difficult in these cases
of minor injury. Delayed recovery is sometimes
due to failure to recognize and adequately treat
a minor fracture. The danger of over-treatment
is not generally' recognized, but clinical observa-
tion has convinced me that it is a hardly less po-
tent cause of trouble. Recovery in a majority of
these cases should be a matter of weeks, at most
of a few months, yet it is a rule rather than the
exception to have these men return for examina-
tion after many' months, still complaining of dis-
ability' and of pain. Sometimes failure to recog-
nize and treat an exi.sting fracture is responsible
for these complaints, but in another large group
of cases, the patient is disabled as a result of
over-, rather than of under-treatment. One is
struck by the number of patients in this second
group who have been under the care of osteopath
or chiropractor. To the average layman there is
a sinister suggestion in any injury to the spine
however trivial, and any' mention of fracture in
this region is apt to be considered the equivalent
of a “broken back.” The supposed existence of
a subluxated vertebra may ordinarily give the
patient addicted to osteopathy or chiropracty only
a pleasurable thrill and a morbid feeling of pride,
and the osteopath one more source of revenue.
484
Journal of Iowa State Medical Society
[December, 1922
But if an accident has preceded the discovery of
this subluxation, the tale is a very different one.
The injured is impressed with the idea that he has
something at least akin to a broken back, and it is
quite evident to him that his disability must ac-
cordingly be great and his compensation or dam-
ages correspondingly large. Sometimes the med-
ical practitioner gives rise to the same pernicious
train of thought — unintentionally in a majority of
cases, I believe — when he speaks of a fractured
spinous or lateral process as a fracture of the
spine. Here, too, the patient is apt to gain the
impression of a “broken back,” and the way is
thus paved for the development of a neurosis.
I believe that prevention in these cases is far
better than any treatment, and that prevention is
possible in a large percentage of cases if careful
diagnosis makes possible efficient treatment and
accurate prognosis. From an industrial and so-
ciological standpoint, cases of delayed conva-
lescence in an employe are peculiarly unfortunate
— the insurance company and employer are apt to
feel that the laborer is malingering, while the in-
jured man himself is convinced that he has been
given inadequate attention and unfair treatment,
and when he at last returns to work, it is in an
antagonistic and resentful frame of mind. The
physician’s first duty is to his patient, and any
complication which delays or prevents complete
recovery, whether the resulting disability is of a
functional or purely neurotic character, should be
guarded against. If the injured man is from the
first given to understand that his injury is a minor
one, and that his disability will not extend beymnd
a certain fixed period of time, he is often ready
to return to work even before the expiration of
that period, ^\'here recovery does not take place
within the anticipated time, a painstaking exam-
ination should be made to exclude the possibility'
of an unrecognized injury, .some pre-existing
])athological condition, some unexpected compli-
cation, and of wilful malingering. In this con-
nection it should be remembered that unilateral
muscular rigidity cannot be counterfeited, that
tenderness to pressure, or anesthesia which is dif-
fuse and fails to recognize anatomical limitations
is neurasthenic or counterfeit ; that in compensa-
tion neurosis and in malingering, the patient who
finds it impossible to perform certain motions
without expressions of .severe pain can be induced
to employ the same muscle groups without evi-
dencing any distress so long as he does not rec -
ognize the significance of the test. It must be
borne in mind that a general knowledge of the
.symptoms associated with a given disability has
(become current coin in any' hazardous industry .
Only a few days ago a workman informed me that
his fellows had assured him that he was a fool for
going back to work so soon when bv judicious
handling, his back injury could be made to yield
him an income for a long period of time.
The patient with a true disability should have
skilled treatment ; short shift should be made of
the malingerer ; for the patient with a compensa-
tion neurosis there is only one effective treatment
— definite and final determination of the period
of di.s^bility', the gold cure with fixed dosage.
Examination and re-examination, fixing and re-
fixing the period of temporary' disability is as
sane a procedure as repeated partial excision of
a malignant growth — such treatment only stim-
ulates the morbid process. The patient with a
compensation neurosis will recover from his neu-
rosis when the irritating element of gain is re-
moved from the etiological complex, and only-
then. Set a definite limit to the period of disa-
bility and compensation, and you have also fixed
the date of recovery-, but in determining this pe-
ri(. d of disability, take due account of the lesions
present.
references
Kleinberg, S. : Traumatic Spondylolisthesis. Archives of Sur-
gery, Chical^o, 1921, iii, 102.
Kuth, J. R. : Lower Back Pain. Journal of Bone and Joint
Surgery. Boston, 1922, iv, 357.
\’ERTEBRAL FRACTURES WITH CORD
INVOLVEMENT*
John Walter Martin, M.D., Des Moines
This subject is of great interest not only- from
a surgical standpoint, but from that of trying to
do something worthwhile for these poor unfor-
tunates with “Broken Backs.” I know of nothing
more pathetic than to see a case of vertebral frac-
ture with complete severance of the cord lyin-^
day after day helpless and dying by inches. As
you see him y-ou hope each day- to find some re-
turn of function, or some little thing happen that
will give you encouragement and a spark of hope
to your ])atient, but the outlook is almost always
gloomy, and after many months in bed with in-
continence of urine and feces accompanied by-
large atrophic ulcers, he dies. As some one has
said these cases live too long.
\’ertebral fractures is too large a subject to
discuss in detail, so I should like to emphasize the
'Presented before the Seventy-First Annual Session. Iowa State
Medical Society. Des Moines, Iowa. May 10, 11, 12. 1922.
VoL. XII, No. 12]
Journal of Iowa State Medical Society
485
following points. Fresh fractures of the verte-
bne, especially of the lumbar and dorsal region,
with partial severance and complete severance of
the cord, and when operation should be per-
formed.
In considering vertebral fractures with cord in-
\olvement, it may be well to remember the an-
atomic considerations of the spine and spinal
cord.
As you know, the structure of the spine is pe-
culiar because of its numerous and complicated
joints and because of the strong ligaments which
embrace the bones on every side.
In the spinal column the forked spine of the
axis may be felt beneath the occiput under deep
pressure. The spine of the third, fourth, and
fifth cervical vertebrae recede from the surface
and cannot be felt distinctly, but by palpation
tlwough the mouth of the bodies of the vertebrae
may be felt down to about the upper border of
the fifth cervical vertebrae.
The spines of the sixth and seventh cervical
vertebrae project distinctly and can be palpat d.
At the bottom of the furrow in middle line of
the back are felt the spines of the dorsal and
lumbar vertebrae.
The spinal cord extends from the skull to the
second lumbar vertebrae, below which point the
spinal canal is occupied by the bundles of nerves
destined for distribution to the lower abdomen,
pelvis, and lower extremities. Between the dura
mater, lining the spinal canal, and the pia mater,
covering the cord, is the arachnoid space, filled
with cerebrospinal fluid, communicating with the
ventricles of the brain, and serving to preserve
the cord from jar and friction.
Injuries to the vertebrae are caused by direct
blow fracturing the arches, by fall on head or but-
tocks crushing the bodies of the vertebrae, by
forced flexions or extensions of the spine causing
a dislocation with or without fractures of the
bodies and articular processes.
The vertebrae commonly fractured are the
fourth, fifth and sixth cervical; twelfth dorsal
and first lumbar. More than one-half of the frac-
tures of the cervical vertebrae are fractures of the
spinous processes. More than two-thirds of the
cases of the dorsal lumbar vertebrae are fractures
of the bodies of these vertebrae. A dislocation
without fracture may occur in cervical region, but
is rare in other regions of the spine.
In the examination of a spinal injury we should
determine the nature of the accident.
1. What does palpation of the spine reveal as to
the nature of the lesion?
2. Where is the level of the lesion?
3. Is the cord partially or completely severed?
4. What does the x-ray reveal; has there been a
fracture with dislocation; fracture through the body,
through the lamina or spinous processes?
The findings in general of vertebral fractures
depend on the location, whether in the cervical,
dorsal, or lumbar region, or whether there has
been an injury to the cord. We have signs of
shock. At the point of injury will be found ten-
derness and pain, abnormal mobility and de-
formity.
The deformity will usually be a backward bend-
ing or kyphosis of the spinal column at the seat
of injury. The chief symptoms depend upon in-
jury to the spinal cord. Generally speaking the
motor and sensory paralysis, either partial or
complete, will be found at the level of the lesion
and extend downward. If the lesion of the cord
is incomplete reflexes at first will be absent, but
will return later. If the lesion is complete re-
flexes will remain absent, with retention and in-
continence of urine and feces, bed sores and great
sloughing areas of the skin on dependent parts of
the body will occur early.
In injuries to the cervical region opposite the
cervical enlargement of the spinal cord, there may
be partial, or complete paralysis of the arms which
may not show in the beginning. Respiration is
diaphragmatic, pain in the arm is constant. If
the injury is above the sixth cervical vertebrae,
there will be anesthesia of the entire arm, except-
ing the shoulder.
If the injury is in the mid cervical region, sa*y —
a lesion at the third cervical vertebrae, it will in-
volve the phrenic nerve. The diaphragm will be
paralyzed and death will occur in a few days. In
injuries of the first two cervical vertebraes, life
may be spared if displacement is slight, but death
is usually instant. According to Gowers “one in
fifty is said to recover.”
The simple distribution of the spinal nerves be-
low the first dorsal makes the interpretation of
the injuries of this region much easier than that
of similar injuries to the cervical or lumbar re-
gions. The arms escape paralysis, the motor and
sensory paralysis extend to the height of the bony
lesion, the patellar reflexes are at first lost in se-
vere types of fracture. If patient recovers there
will be a spastic paralysis.
As the spinal cord ends opposite the lower bor-
der of the first lumbar, any fracture which causes
486
Journal of Iowa State Medical SociET-i
[December, 1922
pressure at that point or below, will involve the
Cauda Equina, partially or completely. Paralysis
of the leg may be partial or complete. Anesthesia
of the lower limbs is partial rather than complete
up to fractured vertebrae, retention and inconti-
nence of urine and feces exist, constant pain :
hyperaethesia may be present both above and be-
low the lesion. Patellar and plantar reflexes us-
ually lost.
After having found out which part of the
spinal column is involved, the next important
question to decide is whether the cord is incom-
pletely or completely severed. This condition
may be due to compression of the cord by dis-
placed bones, extra dural or sub-dural blood clot,
by intra-medullar}’ hemorrhage, cord concussion,
edema, or secondary- softening of the cord, due to
pressure from bone, blood clot, or edema.
According to Frazier in a complete transverse
traumatic spinal cord lesion, there is a flaccidity
of all muscle groups where innervation comes
from segments below the level of the injur}L
There is loss of all reflexes whose arcs lie in seg-
ments below the level of the injury. There is
complete loss of control of the bladder and rectum
and complete loss of all forms of sensation to the
level of the injur}’. The symptom picture is sta-
tionar}’ with tendency toward trophic changes for
the worse. In partial or incomplete lesion of the
cord, there is a spastic condition, with or without
contractures of muscle groups, whose nerve sup-
ply comes from segments below the level of the
injury.
Paralysis may not be total. There is an in-
crease of reflexes whose arcs lie in segments be-
low the level of the injur}-. Presence of the Bab-
inski phenomenon. At times a partial knowledge
that evacuation of the bladder and rectum is tak-
ing place. The loss of sensation is not total and
the symptom picture is not necessarily stationar}’,
and gradual improvement of all symptoms may
be noted.
So then in vertebral fractures the point of
greatest interest and importance is, what damage
has been done to the cord at a particular level?
Has there been a complete destruction? Has
there been an incomplete destruction, or do we
know with reasonable assurance that the cord is
only slightly damaged or not harmed at all ? This
is of the greatest importance because it is the key
to the whole situation and decides when these
cases are operable, and the most opportune time to
operate.
Operation on patients with inconiplete cord
symptoms should be done as soon as possible, that
is, as soon as the patient has reacted from the
shock and the site of the lesion localized and his
exact physical condition known. If within twen-
ty-four to forty-eight hours there has been some
return of the motor or sensory, or more partic-
ularly of the reflex power in the affected extrem-
ities, then the operative procedure is indicated.
Operation should be especially quickly done if
the x-ray has demonstrated that the arch of the
vertebra has been fractured and is projecting into
the spinal canal and causing a compression of the
cord. The constant pressure of the bone will
cause degeneration in the cord which never can
be recovered from. The sooner the pressure is
removed the sooner the regeneration of the cord
begins, and the more certain are we to have func-
tional recover}L
I have found in looking over the literature of
the past eight years on this subject that practicallv
all surgeons are agreed upon the need for early
operation in the cases of incomplete cord lesion ;
but when we come to discuss the question of oper-
ation on cases of complete cord lesion, we find
that the sentiment is almost entirely against the
procedure, for they say it can do no good and
will only hasten death. If we could be sure that
the cord was damaged beyond repair then opera-
tion would not be justifiable; but here a most dif-
ficult problem is presented to the surgeon. Can
we make a positive diagnosis that there has been
a complete transverse lesion of the cord? The
answer must be “Xo.” The difficulty is to de-
termine whether there has been a transverse
crush or whether the symptoms are due to com-
pression or concussion of the cord, or to an acute
edema of cord tissues. Complete absence of func-
tion below the lesion in a spinal fracture does
not always prove that the cord is completely sev-
ered or even that it is damaged beyond repair.
In many cases of fracture of the spine it is im-
possible to state whether the cord is crushed, or
pressed upon by bone, blood or exudate except by
an open operation. If the cord is crushed no mat-
ter what treatment is adopted there will of neces-
sity be a high rate of mortality.
Since we are not able to make a positive diag-
nosis of complete cord severance we have no other
alternative than to approach all cases of this type
as being incomplete lesions, hence justifying early
operative interference. An exploratory operation,
properly done, adds nothing to the discomfort of
the condition and may result in restoring partial
usefulness to the limbs. We are more apt to get
good results if we operate these cases early, for
pressure from a large extra dural hemorrhage, to
say nothing of that from a sub dural hemorrhage
may in a few days time so destroy the spinal cord
VoL. XII, No. 12]
Journal of Iowa State Medical Society
487
that the operation will count for nothing, whereas
if that pressure be immediately released there is a
strong possibility of complete function restora-
tion.
If we could be sure that we had to deal with
hemorrhage in the center of the cord, we would
not be justified in operative measures, but while
the late manifestations of intra-medullary hemor-
rhage are easily recognized the immediate symp-
toms following injury are usually identical with
those of an ordinary transverse lesion, therefore
it seems to me that it would be better to err even
in these cases on the operative side. If for some
reason we happen to wait six or eight weeks with
the result that paralysis of the bladder and bowels
continue with cystitis and large bed sores present,
we may be sure that nature cannot relieve the
case and operation is not only indicated, but
demanded.
In summing up the subject after the study of
the literature and reviewing my own experience
with over twenty cases, on some of which lamin-
ectomy has been performed, but the majority of
which have been treated conservatively, I have
come to the following conclusions ;
That all cases of vertebral fracture with cord
involvement are surgical. After the first three
or four days whether there is return of function
or not, if the patient’s general condition will ad-
mit it, I believe open operation is justifiable. It
is generally agreed that early operation is indi-
cated in an incomplete lesion of the cord, and we
cannot be absolutely sure at any time that the le-
sion is a complete one, but we do know that if we
have a complete lesion the result is a slow but
sure death. The cases we are apt to harm by
surgical interference are usually hopeless anyway,
and if they are not absolutely hopeless there is a
chance for partial if not complete recovery of
function by operation.
Therefore to my mind, in cases of complete le-
sion of the cord, operation is really a justifiable
gamble, with death certain without surgical inter-
ference.
I should like to give a very brief history of
three cases, that have been under my observation
recently, to help bring out some of the points in
my paper. The first case was that of a farmer
whom I saw in consultation.
Case Report
F. S., age thirty-eight, married. No previous his-
tory of illness or injury.
History of Accident — While applying binding pole
to load of hay, pole broke and patient was pitched
head first on frozen ground, a distance of nine or
ten feet. The entire body was paralyzed imme-
diately from the head down. He was able to talk
and move the head from side to side, open mouth
and protrude tongue. No paralysis of any eye mus-
cles, was not unconscious at any time, was unable
at times to move a single muscle or group of muscles.
In the course of a few hours was able to move the
thumb of each hand a time or two and slight move-
ment of each foot. Anesthesia delayed at first, in
forty-eight hours was complete, but gradually re-
turned to normal in five or six weeks. Respiration
was apparently diaphragmatic. Eight hours after
accident, anesthesia more pronounced, retention of
urine, catherized which was necessary for about three
weeks, then voided voluntarily, bowel evacuated by
enemas. No incontinence of urine at any time.
Twenty-four hours after injury. Complete anes-
thesia.
As the patient lived in the country and did not
want to be moved to a hospital. No x-ray was
taken, but a distinct protusion could be felt by in-
serting the finger along the posterior wall of the
pharynx at about the fourth cervical. Not much
improvement for about three weeks, after which the
general improvement was rapid. Six months later
he was able to return to work.
This case demonstrates the importance of noting
early symptoms which is of great importance in de-
termining the prognosis and treatment. The case
was one of petechial hemorrhage into the cord with
dislocation of the fourth cervical.
A. Anderson, age forty, married. Worked for
construction company at Camp Dodge.
Physical and x-ray examination showed that he
had a compression fracture between the second and
third lumbar. There was partial paralysis of the
right side below the level of the lesion, namely third
lumbar. There was loss of bladder and rectal con-
trol. There was area of anesthesia over the sacral
region. Patient complained of numbness in the
legs. The reflexes were lost at first, but returned
on the fourth day and became greatly exaggerated,
but no improvement of the control of the bladder
and rectum. Operation was advised which was done
seven days after accident.
At operation we found fracture of the spinous
processes, second, third and fourth lumbar, and frac-
ture with dislocation of the body of the second
lumbar. The cord was damaged, fragments of bone
with blood clots were removed which were pressing
on the cord filaments. Patient made a good re-
covery. Operative wound healed by first intention.
Pressure syrnptoms showed a gradual improvement.
Diagnosis — Partial paralysis, due to pressure from
fragments of bone and blood clots. Patient returned
to light work two years after accident.
Ray C, age twenty-two. Admitted to Iowa Luth-
eran Hospital December, 1921, with history of being
caught in fall of slate in mine.
Examination — General shock was pronounced, but
488
Journal of Iowa State Medical Society
[December, 1922
patient said, “I feel dead from my waist line down.”
There was complete paralysis from about the twelfth
dorsal down. Loss of all reflexes. Complete loss of
control of bladder and rectum. Complete loss of all
forms of sensation from the level of the lesion down.
Symptom picture did not improve. X-ray showed
fracture of the twelfth dorsal and dislocation of the
first lumbar. Three days after the accident, the
condition of the patient remained the same. A
careful examination by a neurologist. Diagnosis of
possible complete severance of the cord.
Patient and relatives told of the serious condition,
operation recommended, but of course no encourage-
ment was given. Patient refused operation and was
taken home. After four weeks, patient decided that
he might as well take a chance, as he became fully
convinced that he could not get well as he was.
Laminectom}' was done. The spinous processes of
the eleventh, twelfth and first lumbar removed and
the cord was laid bare, and much to my surprise, the
dura was intact and no visible evidence of complete
severance of the cord. The operative wound healed
by first intention and patient was removed home
twelve days after operation. Up to date there has
been very little improvement, but I cannot help feel
that if the patient had submitted to an early oper-
ation, there would have been more of a chance for
some partial return of function.
Discussion on Papers of Drs. Fay and Martin
Dr. William Jepson, Sioux City — Dr. Fay has so
well presented the topic of injury to the spine with-
out injury to the cord that there is little left for me
or possibly for any one else to say except in the
way of emphasizing a few points. One of the points
that I would like to emphasize as brought out by Dr.
Fay is that in few fields has the x-ray been of more
advantage to us than in determining some of the
lesions of the spinal column which we hitherto did
not recognize and probably would not have recog-
nized without its aid. At least I will say that for
myself. Certainly the x-ray pictures that were put
on the screen have shown many things in the nega-
tive, that is, these fractures did not show as clearly
as one could hope for. Please remember that that is
true also when examining them most carefully. And
even with the best x-ray work, and I am sure this is
amongst it, you may find difficulty in being positive
that a fracture does not exist. In other words, I
am quite confident that until the x-ray came to our
aid many of these fractures passed from our obser-
vation with the statement that the condition was
simply a sprain or a traumatic lumbago or whatever
one wished to call it. I recently noticed an article
by Dr. Hibbs of New York in which he mentioned
some nineteen or twenty cases, of which number
only four or five had previously been recognized, and
they had run along for years and appeared before
him with the so-called traumatic lumbago, which
simply means that the individual is trying to do with
his spine what the individual who has a tubercular
condition tries to do with his — to fix it with his
muscles and keep it rigid in order to relieve himself
of pain, and in doing so he not only suffers pain, but
suffers distress. The reason the x-ray is of such
great value is that we cannot by the ordinary symp-
toms of fracture, as crepitus, pain, etc., determine the
existence of fracture of either the body of the verte-
bra or even of the transverse processes. I agree
most heartily with Dr. Fay that in everj^ one of
these cases of fairly marked injury to the back and
where from the history of violence we have a right
to suspect fracture, we eliminate fracture insofar as
possible and even then, if not sure, treat the case as
if it was a fracture, placing the vertebral column at
rest for a period of five to seven weeks. I want to
say furthermore that we should not iqake the patient
too conversant with what we think is the matter with
him. This was beautifully illustrated to me in my
last service, when I happened to be located at a point
where there was a flying field about us. We had in
our wards a number of patients who had come down
and survived, with the result that they had fractures
of various bones. Of a number of such cases I re-
member two instances of men who in coming down
sustained fractures of the vertebral column, and to
this day the}' do not know it and are not bothering
anybody about their sore backs.
Dr. H. C. Eschbach, Albia — I have nothing but
commendations for the paper of Dr. Martin, enumer-
ating as it does the injuries of the vertebral column
with involvement of the cord and presenting in a
very brief manner a fair and adequate picture of such
involvements. As has been said, most of these cases
live too long. To one who has practiced in a mining
country where these cases are comparatively fre-
quent, the picture is one that he approaches with
dread. We have many of them in our country, pa-
tients going about in a hopelessly crippled condition
from fracture of the vertebral column. As Dr. Fay
has pointed out, those cases nowadays are treated by
being put to rest and taking care of the fracture, just
as in fracture of any other bone and securing fairly
adequate results in functional activities for that pa-
tient in the future. But with involvement of the cord
the picture is entirely different. As our essayist has
pointed out, we have no way of determining the com-
plete severance of the cord. The x-ray does not tell
us, the loss of function below the site of injury does
not tell us, whether that cord is completely severed.
The same indications are present in compression of
the cord, in concussion of the cord, in pressure from
blood clot, in acute inflammation, and various other
conditions that may be the result of injury, without
complete severance of the cord. So I think all of
these cases should be approached with an open mind
as to complete severance of the cord. We should
seek to prevent any other complications coming in,
and as soon as shock is over and study of the case
has been completed we should be prepared to do an
open operation by careful exploratory technic, be-
cause interference will not increase the dangers or
difficulties and if there is not complete severance of
the cord, by removing the pressure that exists you
VoL. XII, No. 12 1
Journal of Iowa State Medical Society
489
give a cliance for revitalization of the cord at the
time and some usefulness to that patient in the future.
Dr. Tom B. Throckmorton, Des Moines — I feel
that the two papers which have just been presented
are valuable contributions to medicine. To me they
have been of particular interest, but time does not
permit me to eulogize the efforts of my two dis-
tinguished confreres. In the few moments at my
disposal, I would like to direct my remarks along the
line of hysteria and accident compensation. A few
years ago in the current literature, there occurred
very frequently the terminology “railway spine”
which was coined by a man named Ericksen who re-
ported a large number of cases complaining of spinal
injury following railway accidents. From the time
of the coining of “railway spine,” we have heard the
terms traumatic spine, traumatic neurasthenia, trau-
matic hysteroneurasthenia, traumatic neurosis, and
now we have the term, and I believe best of all.
“traumatic hysteria,” applied to this great group of
cases in which there are objectively no organic le-
sions involving the central nervous system, the en-
tire quota of cases being confined to those individuals
presenting symptoms which are truly functional in
character. We are all agreed that hysteria is a true
disease entity, but it must be borne in mind that it
occurs only in individuals who are pathologically
vulnerable to suggestion. That is to say, of a num-
ber of individuals exposed to the same traumatic pos-
sibilities, the vast majority of those thus exposed
will give no symptomatology of an hysterial nature.
There may be one or two who will develop so-called
traumatic hysteria. The solution of the problem, as
I see it, deals largely with the education of the med-
ical profession to an appreciation of the point
touched upon by Dr. Jepson in his closing remarks,
namely, that it is ofttimes the physician who first
suggests to the patient the possibility that an injury
has been sustained. It is absolutely up to the ex-
aminer who first sees these cases to determine largely
their subsequent course, as to whether those indi-
viduals who may be pathologically vulnerable to sug-
gestion will. have opportunity to react to the uncon-
scious suggestion given by the examiner and thereby
develop a case of traumatic hysteria. Those of you
who are familiar with the literature concerning hys-
teria know of the valuable work that was done by
Charcot years ago at the Salpetriere. Charcot showed
that in the vast majority of cases presenting the
symptoms of hysteria, he could readily demonstrate
a true hysteric herriianesthesia. Later Babinski, his
pupil, demonstrated that unless the case had been
previously examined by some one, no true hysterical
hemianesthesia could be demonstrated unless the ex-
aminer, through his power of suggestion either con-
sciously or unconsciously, suggested to the patient
the fact that he really was searching for an area of
anesthesia. The result was that in over 100 consecu-
tive cases of hysteria examined by Babinski, and not
previously examined by other physicians, not a single
one showed the presence of hemianesthesia. I think
such a finding is extremely important. Furthermore,
Babinski demonstrated that in the vast majority of
the cases, previously examined, the hemianesthetic
area occurred on the left side, due, as he believed, to
the fact that the examiner testing for areas of anes-
thesia, was right-handed in most instances and there-
fore began the sensory examination on the left side
of the patient. The second point of importance I
wish to make is that after educating the profession,
we should proceed to educate the laity that the sub-
ject of compensation is a true economic problem. As
I see it, whenever a railway, street car, or mining
corporation is sued by some individual who claims
organic disease as result of an accident (but who
really has nothing but a functional condition to deal
with), and such an individual receives a verdict for a
large amount of money, while naturally the plaintiff
is the one who profits, it is society as a whole that
suffers. You, and I, and others in the productive
period of life, eventually are the ones who must make
up this loss by reason of the fact that we are all
obliged to avail ourselves of public utility service;
we are all obliged to buy coal and the necessities of
life and the result is that many corporations are
compelled to set aside a certain amount of money to
offset any loss that might occur through spurious
litigation, and hence must sell their products to the
public at a higher price, while all society, like Jones,
“pays the freight.”
Dr. Fay — I have just two things to say; (1) When
the neurologist has sufficiently developed his end of
medical science so that a definite diagnosis of com-
plete transverse lesions of the cord is possible; or (2),
when the roentgenologist has developed his science
to the point where it is possible for him to determine
that a vertebra is dislocated completely past its fel-
low, and that it is, therefore, impossible that the
cord has escaped division, then it will be useless to
operate on those cases which have a complete sever-
ance of the cord.
TUMORS OF THE BREAST FROM THF:
STANDPOINT OF THE GENERAL
PRACTITIONER AND THE GEN-
ERAL SURGEON*
.\rthur De.w Bevan, M.D., Chicago
Mr. President and Members of the Tri-State
Medical Society : It is my purpose this evening
to discuss the subject of tumors of the breast as a
[tractical, every day problem in clinical work, a
])roblem which is quite as important, if not more
important, to the general practitioner than it is to
the general surgeon. I should like to do this in
the simplest possible way and from the standpoint
of my own personal experience with the subject.
It will be necessary also in discussing tumors of
the breast in this particular way to include also a
*Presented before the Tri-State Medical Society of Iowa, Illinois
and Wisconsin.
490
Journal of Iowa State Medical Society
[December, 1922
discussion of the chronic inflammatory processes
which simulate tumors and of the other condi-
tions, either real or imaginary, which lead the pa-
tient and sometimes the medical man to come to
the conclusion that a tumor exists, when, as a
matter of fact, it does not exist. These latter
cases I shall discuss under the general title of
“pseudo-tumors.”
I want to say a word or two in regard to the
history of this subject. In the days of Billroth
and in the days of Gross a good deal of study and
V
attention was given to this general subject and
some definite conclusions arrived at, conclusions
which we have been forced to alter by the knowl-
edge which has been accumulated in the last thirty
years. Billroth presents in his mongraphic article
on this subject in the Billroth-Pettea System of
Surgery a very complete discussion of the subject
up to the time that that article was written. Let
me summarize some of the views which are pre-
sented. First, in regard to the frequency of the
various neoplasms found in the breast, Billroth’s
work seemed to show that carcinoma occurred in
about 80 per cent of the cases, benign tumors in
about 10 per cent, and sarcoma in approximately
10 per cent. During Billroth’s time there was a
great deal more confusion in regard to the proper
surgical procedures to adopt than there is today.
It is quite clear that many of the supposed malig-
nant tumors operated on at that time were not
malignant but benign, and it is also quite clear that
the operation done fell far short of being radical
in the sense that we employ the term today. To
be sure, the breast was removed and very often
the axillary glands, but the complete radical oper-
ation had not as yet been introduced. The per-
centage of recoveries in the cancer cases, because
of the fact that many of these cases were operated
upon late and the operation was not very radical,
was small. On the other hand many benign cases
were operated on with the diagnosis of malig-
nancy.
Some surgeons of considerable experience at
that time took the point of view that very few cases
of cancer of the breast were permanently cured
by radical operation. Since Billroth’s time there
have been these very considerable changes. In
the first place, because probably of several fac-
tors, we are today seeing a much larger percent-
age of benign tumors of the breast than were
seen by Billroth and his colleagues. In my own
work benign tumors today form the majority,
probably somewhere from SO to 60 per cent, of
the tumor cases that come to my service. In the
second place, on account of the more general edu-
cation of the public of the danger of cancer and of
tumors of the breast generally, on the whole
women are coming to us for operation much ear-
lier than they did thirty years ago. In the next
place, following the work of Haidenhein, Stiles,
Halsted, Willy Meyer and others, we are doing
a much more radical operation and one that car-
ries with it much more safety to the patient and
as a result our percentage of cures has increased
very considerably.
Treating this problem as I intend to do in the
simplest and in a practical clinical way, let us ask
ourselves what shall we do with a woman who
comes to us with a tumor of the breast. In the
first place, we must ask the question, has she a
tumor of the breast or not? That is by no means
an idle question. I feel quite confident that I see
at least fifty women a year who consult me for a
supposed tumor of the breast where none exists,
and these form a very interesting group of cases
and one which must be studied very carefully by
every honest, scientific surgeon.
These cases occur especially in two classes of
women, the women who have been badly fright-
ened by the occurrence of cancer in some member
of their family or of some friend and who, be-
cause they have a twinge of pain in the breast, be-
lieve or at least are afraid that they themselves
have a tumor and probably a cancer of the breast
and come directly to a consulting surgeon for
examination. The surgeon examines the case
with great care and finds no neoplasm at all and
most of these women are entirely and completely
VoL. XII, No. 12]
Journal of Iowa State Medical Society
491
relieved by the assurance that they have no tumor
and go on their way rejoicing.
The second group are cases which have been
seen by some general pi-actitioner who has lis-
tened to their story, then examined the breast and
convinced himself, let us say perfectly honestly,
that he could more or less vaguely outline a tumor
in the breast in the position in which the women
complains that she has some pain or tenderness.
These cases then come to the consulting surgeon
of experience who examines them carefully and
finds no tumor of any kind or anything that re-
sembles a tumor, or he may find as not infre-
quently happens, that the woman has a lobulated
breast in which the lobules are separated from
•each other pretty definitely by connective tissue
septa, so that one can pick up one of these lobules
between the thumb and finger and without much
stretch of the imagination imagine that we are
palpating an encapsulated neoplasm.
I must add, too, a third group to these cases ;
that is a group in which a woman imagines that
she has a tumor. She goes to the family physician
and he imagines or believes that she has a tumor
and she is then sent to a consulting surgeon, who
should know better but either does not, or is dis-
honest and is willing to operate on the case for the
sake of a fee. It seems almost increditable that
such a state of things could exist, but yet it is
true beyond peradventure, because I have seen
many cases which have been referred to consult-
ing surgeons where the surgeons have recom-
mended and urged immediate operation for
tumors of the breast where on examination on my
service we found that none existed at all. I have
seen that so frequently that without hesitation I
make the statement that many breasts are oper-
ated on every year in this country where no tumor
exists, some of these through mistake and others
because the case furnishes an opportunity of
making a fee, and one must remember also, a
brilliant opportunity of making a permanent cure
for cancer by amputation of the breast where as
a matter of fact no cancer or even tumor of the
breast has ever existed.
Now let us come to the next practical question,
that is, the class of cases in which tumor undoubt-
edly does exist. A woman comes to your service
with a tumor of the breast. I want to say to be-
gin with that tumors of the breast are definite,
tangible things, like a bean or an olive or an Eng-
lish walnut or an egg or an apple. It is not neces-
sary to strain one’s imagination or eyesight at the
end of the palpating finger to determine the pres-
ence of a neoplasm if one actually exists. In
making the examination one can do very well by
adopting two different methods, first, placing
the flat of the hand on the breast and pressing the
mammary gland with the flat of the hand toward
the thorax and with gentle rotating movement
see if a tumor can be palpated in this way. Usu-
ally it can be. Then in the next place, after de-
termining the location of the tumor that partic-
ular segment of the breast is picked up between
the thumb and finger and the tumor definitely lo-
cated and outlined. After locating the presence
of the tumor, the next step is to answer the ques-
tion— is this tumor benign or malignant, or in
the third place, instead of being a tumor at all
may it be a chronic inflammatory process? In
other words, in determining the character of a
swelling of the breast — and I am now excluding
for the time being acute inflammatory processes
such as acute abscesses — one must answer three
questions : is it a benign tumor, is it a malignant
tumor, or is it a chronic inflammatory process
in the breast?
The differentiation between a benign and a
malignant tumor depends very largely upon the
fact as to whether the tumor is movable in the
mammary gland tissue or whether it is frozen into
the mammary gland tissue. Benign tumors are
almost invariably movable in the mammary gland
tissue. That does not mean that one can move
the tumor on the chest wall, because that can be
done in malignant tumors unless it is absolutely
frozen to the thorax. A benign tumor should be
movable in the sense that when you hold the
mammary gland fixed with the thumb and finger
492
Journal of Iowa State Medical Society
[December, 1922
a benign tumor can be moved in the mammary
gland tissue itself. This is not true of a malignant
tumor, nor is it true of chronic inflammatory
processes in the breast. The simple evidence ob-
tained as to whether a tumor is movable or
frozen-in overshadows in value all other evidence
that can be obtained in mammary gland neo-
plasms. Of course, there are other simple prac-
tical points to consider,- — the presence of a tumor
in both breasts in a young woman of twenty-one
speaks with almost absolute certainty because of
the age and because both breasts are involved
against carcinoma and in favor of the neoplasms
being benign. It goes without saying that in the
breast as in carcinoma elsewhere these malignant
neoplasms occur with much greater frequency
during the cancerous years of the individual’s life,
from forty to sixty years of age.
The usual classical descriptions given in our
text-books of the signs of a malignant tumor in
the breast are for the most part of little value in
making an early diagnosis. Pain, the marked
retraction of the nipple, the marked fixation of
the tumor to the skin, the fixation of the tumor
to the underlying muscles of the chest wall, the
presence of lymphatic nodes in the axilla, and the
evidence of carcinomatous cachexia, most of these
pieces of evidence are of little or no interest to
the clinical surgeon who is anxious to operate on
a patient at a time when there is a good prospect
of permanent cure. They are of rather more in-
terest to the pathologist. There is one piece of
evidence, however, that occurs fairly early and in
comparatively small malignant tumors which
should be emphasized and is of real practical
value, that is, the dimpling of the skin over the
malignant neoplasm and one must, of course, not
disregard, even in early cases, this same condition
which produces a retraction of the nipple.
A malignant tumor of the breast where there is
a good prospect of a permanent cure by opera-
tion is the tumor that is seen so early that few if
any of the evidences of the old classical picture
are present and when, in fact, the diagnosis rests
alone upon the discovery of a neoplasm that is
frozen in the mammary gland ; without any other
pieces of evidence this alone furnishes the evi-
dence upon which the operator acts, and this
malignant tumor of the breast must be also, if we
are to class it as a favorable case, one in which the
cancer is limited to the primary focus and in
which there is not as yet any palpable involve-
ment of the nearest lymphatic node, — the nodes
found in the axilla. •
Now before we discuss the question of the
proper surgical handling of these cases and the
diagnosis, let us take up the subject of benign
tumors of the breast. In order to reduce this sub-
ject to the simplest possible terms, instead of
making any elaborate classification of these va-
rious benign tumors, let me say that in a practical
way we may group these benign tumors all under
the title of adenoma ; this includes simple cysts,
a tumor which may be best described as cystic
disease of the breast, which has been so well de-
scribed by Schimmelbusch that it has been fre-
quently referred to as Schimmelbusch’s tumor
of the breast, a condition which is thought by
some authors to be a cystic disease due to
chronic . mastitis, but which .Schimmelbusch
believes, however, to be neoplastic. I quite
agree with that theory that this cystic disease of
the breast is neoplastic and not inflammatory.
There are to be sure a great variety of benign
tumors which may occasionally occur, such as
lipoma, angioma, enchondroma, etc., but almost
all of the benign tumors of the breast that we
meet with in our clinical work can be referred to
one of three groups, either fibro-adenoma, simple
cyst of the breast or multiple cysts occurring a.'
they do in Schimmelbusch’s disease. Fibro-aden-
oma might again be sub-divided into a number of
varieties such as intracanilicular fibromas intra-
canilicular adeno papiloma, etc., but I think for
practical clinical purposes this is unnecessary.
These fibro-adenomas are encapsulated and very
distinctly movable in the breast tissue when one
fixes the mammary gland firmly against the chest
VoL. XII, No. 12]
Journal of Iowa State Medical Society
493
wall. They vary in .size, they very frequently in-
volve both breasts, and they very frequently begin
in early womanhood, in the twenties. Simple
cysts are also, although not encapsulated, freely
movable in the mammary gland tissue because
they are not frozen in as a malignant neoplasm
and are not surrounded by inflammatory tissue as
in chronic inflammatory processes. A cyst can be
also movable and involve both breasts and may
occur comparatively early in life. Where there
is a single large cyst careful dissection not infre-
quently discloses the fact that there may be small
cysts in close contact with the large cyst. As an
example, one will not infrequently remove a cyst
the size of the yolk of an egg and in close con-
tact with it there may be two or three or a half
dozen small cysts no larger than grains of sago,
but for all practical purposes the cyst is a single
cyst.
The Schimmelbusch tumor is a disease of early
womanhood. It may involve both breasts and it
may be limited to a small area of the mammary
gland or it may develop gradually and involve
most of the mammary gland tissue. As you all
know, in cross section the disease is made up of
multiple cysts varying in size from grains of sago
to cysts the size of a bean or even a small cherry,
forming a picture in pathologic anatomy some-
what like cystic disease of the kidney one sees in
congenital cystic kidney. In this neoplasm there
is frequently no definite capsule. On the other
hand, one of these tumors the size of an egg is
usually fairly freely movable in the mammary
gland tissue because again it is not frozen into the
mammary gland tissue by extensions of the pro-
cess, such as occur in carcinoma or by inflam-
matory processes, such as occurs in chronic in-
flammatory lesions of the breast.
I want to say a word now in regard to sar-
coma of the breast. Sarcoma of the breast is
certainly a rare lesion and I have seen compara-
tively few cases : Of course, in looking over
widely the literature one may find a considerable
number of sarcomas of the breast, cases repre-
senting all varieties of sarcoma, but in my own
clinical work I doubt very much whether sar-
coma has occurred in more than 2 or 3 per cent,
of our cases. In the early development of sar-
coma of the breast it gives us a somewhat con-
fusing picture, midway between a benign and
malignant neoplasm, in the sense that some of
these sarcomas have a distinct capsule and are
freely movable in the mammary gland tissue, but
as they grow larger and the process involves the
tissues outside of the capsule we have the same
frozen in characteristics that we find in car-
cinoma.
Let us now consider for a moment the chronic
inflammatoi-y processes that may simulate tumor,
because, as I said in the beginning of this discus-
sion, it becomes necessary to make a differential
diagnosis in our ordinary clinical work between
these chronic inflammatory processes and neo-
plasms. The chronic inflammatory processes
which I have met with have been three in num-
ber: tuberculosis, syphilis (gumma), and actino-
mycosis. We can dismiss actinomycosis with a
few words as the lesion is comparatively rare and
is one that is not very often apt to be confused
with a neoplasm, though this is possible at .times.
Actinomycosis of the breast is, of course, second-
ary to lung and pleura actinomyocotic processes
extending through the lung and pleura to the
mammary gland, producing hard swellings with
not infrequently fistulous tracts. The swelling is
quite characteristic. This wood-like induration
one finds in almost all actinomycotic processes.
It is associated, as I have said, very frequently
with fistulous tracts and, of course, examination
of the pus and granulation tissue scraped out with
the curet will usually disclose the rods of the
actinomyces or complete characteristic colonies.
Syphilis of the mammary gland is by no mean^
uncommon and one should be on his guard against
the possibility of this simulating malignant dis-
ease. I have several times seen syphilis of the
breast operated upon with a diagnosis of cancer
and have seen one breast sacrificed for gumma
with a diagnosis of cancer and then after the
same process developed in the other breast, by
more careful examination the correct diagnosis
determined and the process cured by proper anti-
specific treatment.
Tuberculosis of the breast may, of course, sim-
ulate malignant disease or benign neoplasm. The
diagnosis, however, on gross section with direct
inspection of the pathologic process is not very
difficult, and inasmuch as these cases of tuber-
culosis seldom if ever give anything like the ty-
pical picture of carcinoma but present character-
istics placing them in the list of cases demanding
visual inspection of the pathologic process before
a radical. operation is made, the correct diagnosis
and correct surgical therapy present in correct
practice no insurmountable difficulties.
As these patients with swellings in the breasts
come to us I believe one could say that in more
than 90 per cent of the cases we can make an ac-
curate clinical diagnosis from examination of the
swelling and determine in this large percentage
494
Journal of Iowa State Medical Society [December, 1922
of cases, more than 90 per cent, whether we have
to deal with a malignant growth, a benign growth
or a chronic inflammatory process. In this 90
per cent of the cases I feel that the clinical diag-
nosis is so definite that we can proceed with our
operative interference without direct inspection
of the neoplastic tissue and in the cases in which
we believe we have a definite carcinoma to deal
with, proceed at once to radical operation ; in the
cases in which we believe we have a benign neo-
plasm to deal with, proceed to a local removal of
the neoplasm first, by making an incision in the
fold under the breast, turning the breast upside
down, removing the neoplasm, obliterating the
dead space in the mammary gland at the site from
which*the neoplasm has been removed, dropping
the mammary gland back into position and clos-
ing the external wound. This course is much to
be preferred, because the scar will not be visible,
as an incision directly over the neoplasm which
will leave a more or less disfiguring scar. Of
course, when we handle a benign neoplasm in this
way it gives us a definite opportunity of examin-
ing it grossly and determining the pathology in
cross section.
This leaves a group of about 10 per cent, of
cases in which we begin our operative procedure
with a feeling that we do not know whether the
tumor is benign or malignant and that we must
first determine this fact before we decide what
procedure, radical or local, should be adopted in
the particular case. Now how are we to de-
termine in this doubtful group of cases whether
a neoplasm is benign or malignant. In answer to
that I will say that almost invariably by exposing
the tumor and by direct section of the tumor and
making the diagnosis from the gross naked eye
pathology. To the surgeon who is trained in
gross pathology nothing is more satisfactory, and
nothing is more definite in the vast majority of
these cases than a diagnosis from the gross path-
ology’ on cross section. Nineteen times out of
twenty or more, the section of a carcinoma is so
definite that a trained surgeon has no question
as to the condition which he has to deal with
when he has cut through the tissue with his knife
and exposed it for inspection. The same is true
of benign tumors. This inspection of the gross
pathology is a much more certain way of a mak-
ing a diagnosis in these doubtful tumors than a
rapidly made frozen section. I have applied this
method in my cases for a long time. I am very-
glad to find that Bloodgood in a recent article on
breast tumors in Binney’s Surgery presents quite
clearly the same conclusions that the gross path-
ology^ can be relied upon much more safely than
a rapidly made frozen section.
This leaves a very, very- small percentage of
tumor cases in which the diagnosis, after inspec-
tion of the gross section, is not absolute or in
which one may be mistaken in his diagnosis. I
doubt very much if this group would furnish
more than one per cent, of all tumor cases and
these are the cases in which a very careful exam-
ination of the specimen after its removal and a
very^ careful study of serial sections are neces-
sary to make a definite diagnosis, and inasmuch as
this is always made, or should be alway’s made, in
these tumor cases, it leaves the situation in re-
gard to this small percentage of very doubtful
cases in this way — that the surgeon makes a diag-
nosis of a benign tumor or a doubtful tumor, re-
moves simply’ the tumor and then submits it to a
veryr extended and careful study^ with serial sec-
tions. That is complete within two or three days
and on the basis of that careful study" if it proves
to be malignant, radical operation is then at once
made.
In connection with this particular group of
cases I want to say that I have no sympathy at all
with the proposition that was preached a few
years ago, that removal of the tumor from the
breast for microscopic examination was bad sur-
gery". If a tumor of the breast is removed and
very’ carefully examined and we devote two or
three days to this examination and study, I can-
not see that any possible harm is done to the pa-
tient if at the end of the third or fourth day ?■
radical operation is made. Cancer cells do not
hop around like the Irishman’s flea. They" extend
from the primary" focus along the lymphatics by a
slow’ process of grow'th just as a pumpkin vine
grows along the ground and not by a kind of a
growth that would develop in the tw"o or three
davs, during which the specimen is being ex-
amined.
Now’ so much for the practical differential
diagnosis betw"een these three groups of cases,
the malignant tumor, benign tumor and chronic
inflammatory process. Now’ w’hat are we to do
with the woman who comes to us w"ith these
sw'ellings of the breast? I w’ould answer w’ithout
hesitation, we are to determine absolutely by some
certain means of diagnosis the condition that is
present. It is not fair to allow’ a case to go
aw"ay w"ithout that advice. Even though a tumor
looks benign we should know" that definitely and
that usually means in the presence of a single
tumor the removal of the tumor for gross and
microscopic examination. There are certain con-
ditions in which a benign tumor might be left
VoL. XII, No. 12]
Journal of Iowa State Medical Society
495
without any operative interference. Let me cite
a few of these. A girl of twenty comes to you
with two tumors in one breast and one in the
other. They are perfectly movable and they are
the size of cherries. They are with almost abso-
lute certainty benign neoplasms, either cysts or
fibro-adenomas. They are so small they are not
disfiguring. Tumors of that kind can be safely
left with the diagnosis that they are benign, but
if they increase in size they should be removed.
Now in connection with these benign tumors I
want to say a word in regard to the prospect of
these benign tumors becoming malignant. I want
to tell the story from my own clinical experience.
Out of three or four hundred or more benign
tumors that we have removed and have been able
to follow in longer or shorter periods, I have
never been able in but one instance and that oc-
curred here in Milwaukee to follow out a case
where we had diagnosed the tumor as benign and
where later the patient came back with a malig-
nant tumor, and from the theory of probabilities,
inasmuch as 10 per cent, of women of cancer age
died of cancer, it would be not at all surprising if
quite a number of women who had benign tumors
of the breast removed later developed carcinoma
of the breast. Certainly there would be nothing
unusual in one carcinoma of the breast in two or
three hundred women who had benign tumors re-
moved from the breast. I cite this because I am
impressed with the fact that there is little or no
reason for us to believe that benign tumors of the
breast remain benign for years and then become
malignant. I feel that that is not true. We must,
of course, recognize the fact that any neoplasm
may change from a benign condition into a malig-
nant one, but I believe it is a verv% very unusual
thing and that it seldom happens and that there
is little more danger of a benign tumor of the
breast becoming malignant than there is of any
other portion of that same breast becoming the
site of a carcinoma. The confusing pictures
which are so often cited of a tumor that looks be-
nign and later becomes malignant are to my mind
usually cases of tumors which have been malig-
nant from the start, that is slowly growing malig-
nant tumors. I feel, therefore, we are not war-
ranted in telling a woman that she should have a
tumor of the breast removed for fear it might
become malignant, because I do not feel that that
is true.
The real problem, of course, of breast tumors
is that of cancer of the breast. Let us analyze
this problem and ask ourselves what are the real
facts in regard to the prospects of cure in cancer
of the breast. Cancer, of course, is beyond ques-
tion originally a local disease and if we can make
a radical operation of the breast when the car-
cinoma is the size of a bean or the size of a
cherry, and the process is absolutely limited to
the breast tissue and has not as yet invaded the
draining lymphatics, there can be no doubt that
the prospects of a permanent cure are excellent.
There can be no doubt, for instance, that much
more than 50 per cent, of the cases of carcinoma
of the breast that are operated upon early before
the axillary glands are involved are permanently
cured by radical operation. Unfortunately, how-
ever, as the cases come to us the prognosis is not
nearly as good. I should say that out of 1000
cases of cancer of the breast that come to well
trained, competent surgeons, probably 25 or 30
per cent, of them are permanently cured by oper-
ation. The moral, of course, is that we should
continue the propaganda, which we have already
begun, through the profession, through the medi-
cal societies and through the special organizations,
such as the Society for the Control of Cancer, to
educate the public and the profession in the im-
portance of having breast tumors in.spected and
properly handled very early.
The best surgical technique for the radical op-
eration of the breast has become pretty well
standardized, that is, the necessity of removing
the mammary gland and overlying skin widely and
underlying pectoralis major muscle and cleaning
out the axillary fat and lymphatics. The dissec-
tion should be so planned that the block of tissue
removed has at its center approximately the cen-
ter of the primary focus; in other words, the dis-
section should be so planned that the periphery
should be as nearly as possible equi-distant from
the primary focus all around. My own expe-
rience has taught me that whenever the lymphatic
glands in the axilla are grossly involved there is a
poor prospect of permanent cure. I want to tell
you why this is so. I want to sketch to you rapidly
the lymphatic drainage of the breast. The lym-
phatics of the breast drain into the axillary glands
and into the lymphatic glands in the anterior me-
diastinum along the internal axillary arterv, into
the posterior lymphatic glands in the posterior
mediastinum along the intercortal arteries, into
the lymphatic glands above the clavicle and also
in a limited way into the lymphatics around the
round ligament of the liver and the umbilicus.
Although the large lymphatics of the axillary
space can be easily palpated and are probably also
the first involved and are involved to the greatest
extent, at the same time it is true that the lym-
phatics in the anterior mediastinum are involved
almost as early. Involvement of the posterior
496
Journal of Iowa State Medical Society
[December, 1922
mediastinal lymphatics follows shortly and then,
of course, the lymphatics above the clavicle and
the lymphatics about the umbilicus, ^^*e cannot
remove the lymphatics in the mediastinal spaces
and inasmuch as when the lymphatics in the axil-
lary space are definitely and grossly involved, we
as a rule at the same time have an involvement
of the mediastinal glands, we have to deal in this
group of cases with conditions which prevent
permanent cure.
Little need be said in regard to the technique
as far as anesthesia is concerned. Drop ether
anesthesia is beyond question the anesthesia of
choice. Amputation of the breast, could be done
with gas and oxygen, but unless there is some
special indication, not nearly as safely as with
drop ether. Thei'e is little or no reason for ever
employing local anesthesia in extensive dissections
and amputation of the breast. The operation, of
course, can be done under local but it seems to
me that it is stretching a good thing to the break-
ing point to adopt local anesthesia in radical breast
work.
There is, of course, little or no mortality from
the operation itself. The prognosis varies as far
as the permanent cure is concerned from 50, 60,
70 per cent, in the very early cases in which the
lesion is limited to the breast and there is no
axillary involvement, to a vanishing percentage of
recoveries in the cases in which the operation dis-
closes a very widespread lymphatic involvement
extending above the clavicle. As a whole, if we
are quite truthful and include all of our cases, I
think somewhere from 25 to 30 per cent, of per-
manent cures in cases actually operated upon are
the results that are being obtained.
Can these results be benefited and improved
by the x-ray ? I think they can. Should radium
be employed? I think not. I think the x-ray is
of verv much more value in the after-treatment
of breast amputations for carcinoma than radium.
I feel personally very strongly that it should be
employed in every case, that it should be employed
by an expert, that it should be employed thor-
oughly but short of any prospect of burning the
patient. The logic is irrefutable. Time and again
I have seen gross recurrent carcinomatous lesions,
the size of a bean or the size of a cherry, disap-
pear under x-ray treatment. It seems perfectly
clear to me that if these gross, visible, tangible
lesions can be made to disappear under the x-ray
that the microscopic group of cells from which
they sprung could be \ ery much easier destroyed
if the x-ray is used immediately after radical
operation. This I think should be ailvised in ev-
erv case. There comes a time, of course, in hope-
less cases where the x-ray evidently is of no value,
where it holds out no prospect of benefit and
where some other agent than the x-ray such as
morphine had better be used for the purpose of
making the patient as comfortable physically and
mentally as possible without adding any possible
injury from x-ray management.
In brief and in a simple way this seems to me
to be the story of tumors of the breast as far as
it can be told from the knowledge we possess to-
day. These cases furnish us a real problem and a
large problem and an every day, practical problem
that must be met by the general practitioner and
by the general surgeon and it can be met in the
right way, if as a profession we educate the pub-
lic, and we help to educate ourselves and our col-
leagues so that there will be a widespread knowl-
edge among the laity of the importance of tumors
of the breast, and the general knowledge that a
small beginning carcinoma of the breast can be
cured by proper surgical operation, that neglect
of these cases means almost certain death, and it
can be met properly only if the profession give to
these patients the benefit of early diagnosis and
early and proper surgical treatment. And may I
emphasize the importance of not only giving pa-
tients with cancer of the breast the benefit of
proper radical operative treatment, but of also
treating those patients with benign tumors not by
radical but by conservative methods.
PROGRAM OF THE AMERICAN COLLEGE
OF SURGEONS*
Franklin AIaktin, IM.D., F.A.C.S., Chicago
Director-General, .\merican College of Surgeons
The American College of Surgeons is a societ\'
of five thousand surgeons of the United States
and Canada, who have allied themselves in this
association for the purpose of improving the ser-
\'ice which they are rendering to their patients. It
comprises only a part of the one hundred and
forty thousand doctors of the continent, who
represent a profession which has already endeav-
ored to command the respect of its people by
serving them faithfully and honorably.
The surgeons of the American College of Sur-
geons are putting forth every possible effort to
make better surgeons of themselves ; to aid in
providing better training for the speciali.sts in
medicine who are called upon to do surgery ; to
discourage unnecessary surgery by insisting upon
a thorough diagnosis before an operation is at-
*Sunimary of -\ddress delivered before meeting of the Tri-State
District Medical Society, Milwaukee, Wisconsin.
VoL. XII, No. 121
Journal of Iowa State Medical Society
497
tempted ; to encourage j)hysicians who desire to
become surgeons to take a practical training in
the art of surgery with surgeons of recognized
ability before operating independently upon their
fellow men and women ; to encourage the estab-
lishment and maintenance of well-equipped hos-
pitals in which the surgeon will have every fa-
cility for determining the ailment of the patient ;
and in which he can safely operate upon his pa-
tients ; hospitals with safe nursing, safe sterilizing
outfits, proper operating room facilities; hospitals
that insist on honest and competent management
and an ethical, moral and competent medical staff
practicing scientific medicine.
The American College of Surgeons believes
that the best surgery that can be done by the most
expert diagnostician, in the safest environment
that can be secured, is none too good and that ev-
ery man, woman, and child is entitled to the very
best surgery that can be obtained.
The American College of Surgeons believes
that there is no state in the United States or no
province of Canada that cannot furnish the very
safest kind of surgery for its citizens if the medi-
cal profession and the citizens of the towns and
cities of such states and provinces will get to-
gether and cooperate in helping each other in this
problem.
The American College of Surgeons believes
that this is a problem that interests laymen and
medical men alike, and that the medical men can-
not work it out without the sympathy, the aid, and
the cooperation of all intelligent citizens.
During the last two decades, whole cities,
states, and nations have improved their health be-
cause of the medical profession and its addeci
knowledge. Whole armies have been saved from
the ravages of diseases which but a short time ago
devastated them far more than did the attacks
and bullets of the enemy. The whole medical pro-
fession stands for health, strength, and the whole-
someness of all the people whom it serves. It
stands for its own honor, and for science and it ’s
opposed to quackery in any form.
The American College of Surgeons believes
that every surgeon should prepare himself for his
important work by a thorough education in the
science and the art of his specialty; by a labor-
atory training in the technique of surgery ; by an
association in actual surgical work with a surgeon
of ability and experience; and by a hospital train-
ing of at least two years, during which period he
should become familiar with diagnostic methods
and the pre- and post-operative treatment of sur-
gical patients.
The American College of Surgeons believes
that a man who is ambitious to become a surgeon
or a surgical specialist should learn to do surgery
as an apprentice to or as an assistant to an expe-
rienced surgeon rather than to learn to do surgery
by himself, attempting to operate upon human
beings without having at his side an expert sur-
geon.
The American College of Surgeons believes
that every individual who practices surgery should
not only be thoroughly educated as a medical
man, thoroughly familiar with and drilled in prac-
tical surgery, that he should do his work in an ap-
proved environment, but that he should be a man
of the highest honor in his financial dealings with
his patients and with his fellow practitioners.
The specialists of surgery who are represented
in the American College of Surgeons are eye sur-
geons ; ear, nose, and throat surgeons ; obstetri-
cians and gynecologists ; orthopedic surgeons, and
general surgeons — specialists who must be con-
sulted by every citizen one or more times during
his lifetime.
Instinctively, you will ask : “How can a man
who belongs to one of these specialties and who
has no influence or special acquaintance become a
member of the American College of Surgeons?’"
The answer is very simple. Any man who is a
legalized practitioner of medicine can apply for
membership at any time. Any friend of any sur-
geon can ask to have an application blank sent to
a surgeon. However, the surgeon must then
qualify by following the program that has been,
outlined.
Thus any surgeon who is qualified profession-
ally and who is honest may become a ^Fellow of
the College of Surgeons. Is it not possible for
some jealous competitor who is in the College to
keep out an eligible applicant? That would be
possible if our information about the candidate
came from one source, but with our system of im-
partial investigation from several sources, such
action is detected and frustrated. Such un-
worthy attempts may delay action, but they can-
not prevent final favorable action on a qualified
candidate.
Why should the layman be interested in the
program of the American College of Surgeons?
The layman should be vitally interested in the
program and the success of the American College
of Surgeons because that organization stands for
the upholding of scientific medicine and honest
methods in the practice of scientific medicine.
What is scientific medicine?
Scientific medicine represents the practice of
men who have been educated in the fundamental
facts as revealed in the practice and research of
498
Journal of Iowa State Medical Society
[December, 1922
the science and the art of sanitation, hygiene,
medicine, and surgery.
Scientific medicine teaches how to prevent the
pollution of drinking water and makes it safe for
you and your family to drink from the public hy-
drant in any city of the world that is under proper
sanitary control.
Scientific medicine made it possible for General
Gorgas to eradicate yellow fever and malaria
from Havana and Panama, and in so doing es-
tablished methods that have transformed these
former pest places of disease into garden health
resorts of the world; methods which when ap-
plied to the tropics of the earth will make these
countries the center of culture and civilization.
Scientific medicine, not quackery, was selected
by our government to care for our soldiers in the
late war. Our soldiers, at first bewildered by tlie
activities of the medical department, soon learned
that their lives and comfort depended more upon
the medical officers than upon any one other
factor. In that first examination that was so irk-
some to them, one-third of their apparently
healthy comrades were rejected because of slight
physical defects, many of which, under early ad-
vice, were permanently remedied; they were vac-
cinated against small-pox, typhoid, and para-ty-
phoid ; they were taught what to eat, and how to
exercise ; their living quarters were regulated and
ventilated, and their food and water were guarded
against pollution; they were subjected to frequent
inspection, and a constant effort was made to
keep them well instead of waiting until they be-
came ill before treatment was instituted.
They went in, many of them, as weaklings;
and they came out, notwithstanding their hard-
ships, as physically strong men. And this physi-
cal care has imparted to them a sense of ade-
quacy and well-being that they had never before
possessed. No wonder that they are asking;
“Why can’t this same care be extended to our
wives, to our children, and to others in the normal
community life?”
Scientific medicine aids us to conduct our hos-
pitals, dispensaries, and asylums in a manner to
insure the very highest degree of efficiency in
caring for the sick in these institutions.
Scientific medicine has taught us how to diag-
nose surgical diseases, and how to operate in the
safest possible manner and secure the most de-
sirable results.
Scientific medicine is based on experimental
medicine and surgery, and wherever animal ex-
perimentation will produce the desired results and
thus not risk the lives of human beings, it is based
upon animal experimentation.
finally, all educated people know what scien-
tific medicine has accomplished in providing anti-
toxins and sera for the prevention of diphtheria,
typhoid, and para-typhoid fever ; what vaccina-
tion has done to prevent small-pox ; and what the
application of sanitary measures has done to-
ward ei'adicating common diseases.
The American College of Surgeons besides
standing for scientific medicine also endeavors to
establish among the practitioners of surgery a
high standard of honesty and ethics.
Every surgeon who becomes a Fellow of the
American College of Surgeons must subscribe to
a pledge which stipulates that he shall not divide
the fees received from his patients with his fellow
practitioners in order to increase his business. In
other words, he must not buy and sell his patients
on a commission basis.
ETHICS IN FRACTURES*
F. A. Hennessey, M.D., Calmar
Coincident with the somewhat chaotic condi-
tion of mankind since the close of the World
War, and probably in a measure due to the nu-
merous theories that have been advanced in ethics
during the past centuries, so many theories in fact,
that almost any type of an individual can find one
to justify his acts, and their consequences from an
ethical point of view, while the legal interpretation
of the facts might be directly opposed to the in-
dividual point of view.
Some interesting facts are brought to our at-
tention, when we review the number of cases of
fracture that find their way into court procedure,
following treatment and observation by some phy-
sician who did not render the first attention after
the accident.
No doubt many of you are familiar with the
statistics I am going to quote, but lest there may
be some one who is not, I feel it worth while to
give them to you as I can see no reason why any
physician would not care to know them. These
are given to me by the secretary of our State So-
ciety as furnished him by the .Medical Defense
Committee.
Over a period of fourteen or fifteen years there
have been over 194 cases commenced and of that
number seventy-nine have been fractures. X-ray
bums come next, being six in number. Ap-
pendix cases five, and then various ones at three,
two and one. Why such a large percentage of
•Read before the Austin Flint-Cedar Valley Medical Society, New
Hampton, Iowa, July 12, 1922.
VoL. XII, No. 12]
Journal of Iowa State Medical Society
499
fi'actures ? Surely they are not as frequent as ap-
pendicitis or confinement cases.
From April 30, 1921 to April 30, 1922 there
have been twenty-five new cases filed, suit having
been brought in thirteen of them — seven of these
being fracture cases. No doubt an occasional
case results from a very manifest deformity, but
that does not prove that the individual may not
have a functional result that is almost normal. I
would like to ask what physician seeing such a
case six months to two years after the original in-
jury, without knowing the facts surrounding the
case, such as type of patient, the living up to in-
structions, etc., can justify himself in passing
judgment in the presence of the patient, or what
is still worse appear on the witness stand giving
evidence, without a knowledge of the facts on
which to base his judgment. And yet such things
have occurred and will no doubt continue to oc-
cur, but let us hope less often. During the past
year I have seen a member of a county society
appear as a witness against another member of
the same society and as near as I have been able
to determine his motive was utilitarian, as I be-
lieve he expected to receive the fee of an expert
witness, but unfortunately he received the noble
wages of $8 or $9.75. A peculiar but rather com-
mon mistake of ethics entered into, causing this
case to appear in court, an excellent practitioner,
a graduate of one of the best medical colleges of
North America who gave an x-ray picture to the
patient.
I have not been able to determine whether the
medical profession of any other country has a
code of written ethics ; it is possible that the coun-
tries of Europe with long years of training in
common custom do not need to have one; how-
ever, I do not think that we are quite ready to dis-
card our code of ethics in this country, judging
from conditions as we find them, and a person is
led to believe that the code of ethics owned by
most of us is liable to be somewhat of a dusty
book in the book case. All physicians are sup-
posed to have studied this code and to be familiar
with its requirements.
The moral claim which it has upon you rests
not upon any obligation of personal friendship to-
wards your fellow practitioner, but upon the fact
that it provides for every relation, emergency or
occasion, and is found on the broad basis of jus-
tice and equal rights to every member of the pro-
fession.
To this code, in a great measure, is due the
binding together and elevation, far above ordinarv’
vocations, of the medical profession of this coun-
try, and the esteem and honorable standing which
it eveiy where enjoys.
Our attention should be called to the fact that
the foundation of ethics does not change ; the ap-
plications may vary, but the principles themselves
remain unalterably fixed. No physician may al-
ter the essential principles of medical practice nor
deviate from them without violating the moral
order.
I imagine a fine discussion could be provoked
at this point as to whether or not ethics is vari-
able. But suffice it to say that certain fields of
investigation, too, present us with definite forms
of knowledge, away from which the fairly well
informed cannot be forced to turn. In physics
for instance, we have the law of gravitation ; in
mathematics the multiplication table, etc. Every
natural science will afford illustrations bearing
on this head of generally accepted first principles.
Any theory which makes of ethics a matter of
expediency, policy or sentiment must be a failure.
I would like to repeat this again, that any theory
which makes of ethics a matter of expediency,
policy or sentiment must be a failure. Eor the
violation of this statement is the occasion of this
paper. Is it not a sad state of affairs to find a
Fellow of the American College of Surgeons, who
disregards his code of ethics, and out of pure
sentiment, giving damaging evidence against an-
other member of that organization, in a case in-
volving a fracture? Conscience is an act, a prac-
tical judgment on one’s own action in some par-
ticular case. It is a rational faculty, not an emo-
tional, sentimental power.
It has been my intention to treat this subject
largely from the point of view, that a violation of
ethics is the cause of such a large percentage of
fractures entering into medico-legal cases. All of
these cases without exception usually pass
through the hands of two or three practitioners
before the climax is reached and if it is proper
in this paper I would like to suggest a plan of
procedure when such a vase comes into your
hands. First- — Never give a patient an x-ray plate
or spend too much time interpreting it to the pa-
tient, as they have many faces and angles, and it
is very easy for them to see the wrong one.
Second — When called to treat a case previously
under the care of another physician, especially if
the patient is dissatisfied with his treatment, be
carefully just. Let your conversation also refer
to the present and future, and not to the past. Be
guarded in your words and actions, and take no
unfair advantage of some other physician’s appar-
ent errors. Third- — Always bear in mind that two
wrongs never make right.
500
Journal of Iowa State Medical Society
[December, 1922
In conclusion, a word concerning the reward
for different vocations in life : we speak of wages
as due to common laborers, of a salary as paid to
those who render more regular and intellectual
services; of a fee as appointed for official and
professional actions.
Wages may be measured by the time bestowed,
or by the effect produced, or by the wants of the
laborer to lead a life of reasonable comfort ; a
salary is measured by the period of service ; but a
fee or honorarium is not dependent on time em-
ployed, or on needs of support, or on effect pro-
duced, but is a tribute of gratitude due to a special
benefactor. This is the ideal which makes the
medical profession so honorable in society. Let
us not by anger, greed or malice destroy this sub-
stantial foundation on which our predecessors
built so well.
MISTAKES IN THE TREATMENT OF
FRACTURES*
How'ard L. Beye, M.D., Iowa City
(From the Department of Surgery, State University of Iowa)
There is probably no single group of cases
which causes a physician more worry and gives
him less satisfaction, no matter what the outcome,
than fractures. In this group of cases the phy-
sician has constantly before him the ghost of civil
action in case the patient does not get a result
which he feels he is entitled to, whether the seem-
ingly poor result is due to ignorance or negli-
gence on the part of the physician, or due to the
nature of the injury itself. In truth all too fre-
quently poor results in these cases are due to mis-
management on the part of the physician respon-
sible, because the fundamental principles involved
in the treatment of fractures are either not under-
stood or are neglected, and it may be very diffi-
cult to explain away the poor result to an inter-
ested jury. Unfortunately, these cases will often
times be brought to court when the physician has
done everything humanly possible to obtain a sat-
isfactory result.
It is therefore incumbent upon every man who
assumes the responsibility for the care of a frac-
ture to exercise careful judgment, to give con-
stant attention to every detail and to employ ev-
ery available means to the end that the best result
possible shall be obtained. This is necessary not
only that the patient may obtain the best possible
result, and of course that should be the primary
*Read before the Austin Flint-Cedar Valley Medical Society,
New Hampton, Iowa, July 12, 1922.
consideration, but also that the physician himself
may be fully protected in the eyes of the law.
In the surgical service of the University Hos-
pital many cases of fracture are treated, both re-
cent and old. All too frequently cases are sent to
the hospital when the initial treatment has failed
to promise a satisfactory result, but too late for
the patient to be given that treatment which
would have been chosen had the case been seen
early. It is oftentimes difficult honestly to pro-
tect the doctor who has had charge of the case
from the criticism of the patient or relatives. In
this paper I will bring out the errors which are
more commonly made in the treatment of frac-
tures. These errors are not confined to the gen-
eral practitioner. In our hospital service we must
consequently be on the watch to see that all of the
details essential to the proper treatment of frac-
ture cases are carried out, and some of the un-
satisfactory results which we have had are di-
rectly attributable to failure to observe these fun-
damental principles.
Errors in Diagnosis
The greatest number of bad results in fracture
cases are obtained because of failure to recognize
that a fracture is present. This is due to incom-
plete examination of the site of injury and es-
pecially to failure to have x-ray plates made in
those cases where such diagnostic aid is clearly
indicated.
In the examination of a patient to discover a
fracture the physician must not expect that there
will be present the old text-book signs of crepitus,
false point of motion and deformity. When these
are to be found the diagnosis could be made by a
freshman medical student. In indefinite cases
the history of trauma and the presence of ten-
derness over bone are the two most important
points in the diagnosis. Loss of function may
be strikingly absent. In the examination of the
injured limb it is invaluable to compare the find-
ings with the uninjured limb.
There is very little excuse for failure to use the
x-ray in the diagnosis of bone and joint injuries.
It is extremely uncommon that any patient is in
such condition that he cannot be transported to a
neighboring town or hospital for such examina-
tions. Except in such instances the only legiti-
mate cause for failure to use the x-ray wall be
refusal on the part of the patient to incur the
expense or the trouble, and in such cases it is
best for the physician to have such refusal in
writing with the patient’s signature attached.
There are a certain group of fractures which
seem to be particularly difficult of diagnosis un-
VoL. XII, No. 12
Journal of Iowa State Medical Society
501
til too late to obtain satisfactory results by proper
treatment. Of these, fracture of the neck of the
femur heads the list. This is frequently diag-
nosed as a sprain or a bruise and all too fre-
quently as a dislocation, and in the latter case the
resultant manipulation is likely to be a very haz-
ardous procedure for the patient. The classical
signs and symptoms of fracture are frequently
absent especially in the impacted fractures. If
physicians would realize that any fall on the hip
in a patient over fifty years of age is likely to
produce a fracture of the neck of the femur
many errors in diagnosis would be obviated, and
it should also be remembered that a dislocation of
the hip in a patient over fifty is a rarity.
Colies’ fracture with impaction and without the
typical silver fork deformity is frequently over-
looked, the diagnosis here being made of sprained
wrist. In this type of case careful examination
will demonstrate a very definite and usually
marked line of tenderness just above and distinct
from the line of the wrist joint. It should be
borne in mind that in these cases there is fre-
quently an associated sprain of the wrist. Frac-
ture of the neck of the humerus is commonly
diagnosed as a sprain or as a dislocation of the
shoulder. As in a fracture of the neck of the
femur considerable damage may be done by the
manipulation instituted in attempting to reduce
this supposed dislocation. An impacted fracture
at this site is not infrequently overlooked en-
tirely until many days after the accident the pa-
tient consults his physician again because of
continued pain and loss of function. A Pott’s
fracture without deformity may simulate a
sprained ankle unless the examining physician
takes care to localize the tenderness which will
be present distinctly over the line of fracture. In
this type of case the complete loss of function
which one associates with fracture may be absent.
A greenstick fracture of any tong bone, oc-
curring in children especially, is very easy to over-
look. The classical symptoms of fracture are
absent and the local tenderness is often not
marked. You have all seen cases I am sure in
which there has not been sufficient discomfort
to cause the patient to consult a physician until
several days had elapsed after the injury. This
type of fracture is particularly likely to involve
either one or both bones of the forearm, and the
clavicle, tibia and femur less commonly. Frac-
tures which are very likely to be undiagnosed in-
volve the scaphoid of the carpus, the astragulus,
and a compression fracture of a vertebral body
which does not produce cord or nerve lesions. All
of these three may cause considerable trouble ai
a variable period after the injury.
Failure of the fracture to unite is the greatest
source of danger in those cases in which fracture
has not been diagnosed and treatment therefore
not carried out. This is particularly true in cases
of fractures through the neck of the femur
whether impacted or not. Another cause of bad
result in these overlooked cases will be a deform-
ity which tends to increase. In the process of re-
pair of a fracture there is always some bone ab-
sorption. In a greenstick fracture or an impacted
fracture this absorption may so weaken the bone
in the line of injury that the muscle tensions of
the extremity or the stress and strain of weight
bearing may cause deformity and it may be this
symptom alone which takes the patient back to
his physician. It is worth while noting that this
bone absorption may often times be used to an
advantage by the physician to obtain the correc-
tion of an angular deformity in an incomplete
fracture which could not be overcome at the time
of the initial care.
Excessive callus is often times developed in an
untreated fracture due to the stimulation of the
bone by movement in the fracture line. This not
infrequently will lead to mechanical interference
with function especially when the fracture is in
the neighborhood of a joint or tendons. Another
end result may be persistent pain and swelling
even though the fracture may be healed.
Errors in Technic
Imperfect reduction is the cause for the great-
est number of failures after error in diagnosis.
In this group it is usually unfair to bla^re the
physician who has managed the case, because the
nature of the fracture may have been such that
better reduction was impossible. Granting that
every care has been used to obtain satisfactory
position of the fragments, the physician is very
much at fault if the result has not been carefully
checked up by x-ray findings, and it should not
be necessary to state that a single plane view is
not adequate. Plates must be taken in two
planes, which are at right angles to one another.
If unsatisfactory reduction has been obtained,
the physician tnust not be satisfied until further
attempts have been made. If these fail then he
must decide whether the functional result which
will probably be obtained in the case will be satis-
factory, or whether an operative reduction should
be done. It is always best to talk this matter
over very frankly with the patient or his relatives,
and the responsibility for decision should be
shared by them after the facts have been carefully
502
Journal of Iowa State Medical Society
[December, 1922
studied. Not uncommonly, the unfriendly feeling
that a patient will have toward his physician will
be due to the suspicion on the part of the patient
that the doctor has not been frank and honest
with him in the handling of his case.
The value of the fluoroscope as an aid to the
reduction of fractures has not been sufficiently
stressed by writers on fractures. It is of ines-
timable value in fractures of both bones of the
forearm in which condition satisfactory reduction
is so difficult, in transverse fractures of the shaft
of the femur which seem so easy of reduction and
are usually so stubborn, and to a less extent in
fractures of the tibia.
Improper immobilization is another cause for
poor results. The usual mistake made is to im-
mobilize insufficiently. The common splints that
one sees in most doctors offices are too fre-
quently unsatisfactory. Plaster of Paris has no
equal as the means of immobilizing an extremity
for a fracture but it must be used skillfully and
with judgment. One of the fundamental princi-
ples in the immobilization of a fracture is that the
joint above and the joint below the line of frac-
ture should be included in the immobilization.
This is a rule which is frequently overlooked and
there are few exceptions to it.
Any splint if applied too tightly may be the
cause of serious trouble. Pressure necrosis over
bony prominences is the most common. This can
be obviated by careful protection of bony points
by padding. It should be very strongly em-
phasized in this connection that a splint must not
be used to overcome a deformity by exerting pres-
sure against it, but is only a means of holding the
part inamobile in a desired position after reduction
has been accomplished. Another vicious end re-
sult is due to interference with the circulation
from an improperly applied splint. This is mosi
likely to occur in the use of plaster as a circular
bandage. Fortunatel}- this is not a common dis-
aster, but a Volkmann’s contracture is one of the
tragedies of surgery.
Immobilization in an improper position may be
contributory to an unsatisfactory end result.
Fractures of the lower end of the humerus should
be dressed with the elbow in as extreme flexion as
can be obtained without interfering with the
radial pulse. This allows of the maximum of
flexion in case there is to be limitation of motion
when union has occurred. A Pott’s fracture
should be dressed with the foot at right angles
and slightly inverted so as to overcome the tend-
ency to flat-foot which often times is the cause
of a bad result following this fracture. A frac-
ture of both bones of the forearm should be
dressed mid-way between supination and prona-
tion. In this position the radius and ulna are
farthest apart and the chance for synostosis is
minimized. The fracture through the neck of the
humerus is best immobilized with the arm at right
angles to the body and in abduction. This in-
sures the greatest range of motion in the shoulder
joint. A fracture through the femoral neck is
best treated by the Whitman position — complete
abduction with cast immobilization — to insure the
proper angle between the shaft and the neck so
that coxa vara will not be the cause of bad func-
tion if union occurs. These are just a few of the
common fractures in which the position of im-
mobilization is important to insure the most satis-
factory end result.
Too short a period of immobilization is another
cause for poor fracture results. This is partic-
ularly true in fractures of the femur. A physi-
cian is usually too anxious to get his patients up
before sufficient hardening of the callus has oc-
curred to warrant stress and strain being put upon
it without injury. Gradually increasing deform-
ity may then take place such as the development
of coxa vara in fractures through the femoral
neck, or bowing in a femoral shaft fracture or in
a fracture of both bones of the forearm. Exces-
sive callus may be stimulated with functional in-
terference, or the fracture may remain persist-
ently painful and tender.
Principles Which Should be Observed in the
Treatment of Fractures
The x-ray must be used; for diagnosis, to de-
termine the reduction which has been obtained,
and to demonstrate healing. Plates must be made
in two planes at right angles. Skiagraphs taken
of the corresponding uninjured and injured areas
on the same plates are very instructive and may
be necessary when an epiphyseal line confuses.
The fluoroscope is of the greatest value as an
aid to reduction in certain fractures.
Immobilization of an extremity should include
the joint above and the joint below the line of
fracture.
Bony prominences must be protected.
Fractures should be reduced as soon following
the injury as possible. Do not wait for swelling
to subside as there is no surer way to control the
swelling than by reducing the fracture. The
longer deformity exists the greater and more pro-
longed will be the swelling with increasing dam-
age to the soft tissues.
When using plaster of Paris circular casts on
an extremity the toes or fingers should be left
exposed to determine the circulation. Do not ap-
VoL. XII, No. 12]
Journal of Iowa State Medical Society
503
ply a circular cast unless the patient will be un-
der your observation for at least twenty-four
hours following its application.
Do not control the pain of a fracture following
the application of a splint by morphine. If the
patient is having sufficient pain to require mor-
phine you must assume that the splint has not
been applied properly and is doing damage.
Give the patient positive and definite instruc-
tions as to when he should return to you and what
he should do following the removal of splint or
cast. Lack of such instructions may lead to trou-
ble.
Keep accurate records of all procedures relat-
ing to a fracture case.
If the result following attempted reduction is
not satisfactory, make up your mind to that ef-
fect soon, take the patient into your confidence
regarding the true conditions and ask for a con-
sultation.
Conscientious massage and careful active and
passive motion following the removal of splints
will aid markedly in the functional result.
THE LABORATORY PRACTICE OF
MEDICINE*
H. E. Robertson, M.D.,
Section on Pathologic Anatomy, Mayo Clinic
It is not my purpose to detail the history of the
development of this branch of medical science.
Many of you have lived and practiced medicine
during the period in which have been established
the greater number of the multitudinous labora-
tory procedures now in vogue, and the story of
their origin and growth, interesting as it might
prove, is not germane to the theme which I wish
to discuss.
I would like to emphasize, however, the huge
proportions to which this side of medical prac-
tice has grown. From the little shelf and the old
sink in the back office, with a test tube or two, an
alcohol lamp and a few ounces of nitric acid, to
the extensive suites of rooms housing roentgen -
ray and radium appliances, serological and bac-
teriological apparatus, workers in blood chemis-
try, in gastric and urinary analysis, in basal
metabolism, in tissue pathology, with adjacent
laboratories for application of the experimental
methods in the modern study of disease, is such a
monstrous “jump” that the mind can hardly suc-
cessfully comprehend all of the complexities of
the present situation. In former days the physi-
•Presented before the Iowa and Illinois Central District Medical
Association, Davenport, Iowa, July 13, 1932.
cian who was fortunate in his education and pro-
gressive enough to possess the apparatus might
make a blood count or a gastric analysis; at any
rate if his patient were to receive the benefits of
an examination of the urine, this examination, or
any other test, must perforce be made by the
doctor himself in his own office and in the rush
and hurry of the duties of a general practitioner.
Today it is just as impossible for the physician to
do his own laboratory work as it is for any one
person to do all his laboratory work for him. A
whole corps of specialists with trained technicians
are demanded and in each branch the methods
have become so highly individualized that there is
little or no overlapping between their various
fields. The roentgen-ray worker is no longer a
tissue pathologist and the serologist oftentimes
couldn’t make a blood count or determine the al-
kaline reserve, if his life depended upon it.
The patient of a few years ago came into the
doctor’s office and everything, history, examin-
ation, tests, and treatment, even to the medicine,
were furnished in that office and by the doctor
himself.
The patient of today passes through the hands
of a score of doctors, his ailments are critically
examined by experts in each field, every import-
ant physiologic function is weighed by ingenious
balances and the impairment of any vital reserve
is judged by some objective standard. The sum
total of all these efforts, carefully reviewed, will
often tear away the mask from insidious or early
disease processes and throw into clear relief the
hidden sources of weakness. The danger exists
that in the tendency to exalt the mere machine the
desired work which it is to perform will be given
secondary place, that the best interests of the
patient will be replaced by the best interest of his
physician, that mechanical methods, instead of
serving as useful adjuncts to diagnosis, will be
overemphasized, to the neglect of that careful
study of the patient himself without which no real
progress in the prevention and cure of disease can
ever be achieved.
This danger is sometimes so real that the end
result may appear to have become a travesty on
the true practice of medicine, a reductio ad ab-
surdum.
And so indeed the result would actually be,
if it were not for two equally good and sufficient
reasons. The first is that no system for the prac-
tice of medicine which ignores the human ele-
ment can ever be a success, and the second is,
that the more painstaking, the more careful, the
more thorough the practice of medicine becomes,
504
Journal of Iowa State Medical Society
[December, 1922
the better in general will the best interests and the
welfare of the patient be conserved.
The surest indication of the mind growing old,
of which I am aware, is the tendency to select
the best things of the past and by comparing them
with the worst features of the present exalt the
former and decry the latter. “There were giants
in those days’’ is the favorite topic of conversa-
tion, whenever a few greying heads gather to-
gether, and doctors are no exception. I have al-
ready given evidence of this tendency and I need
only add a few remarks about the wonderful old
fashioned family physician, his powers of diag-
nosis, his skill at getting the best results under the
worst conditions, his ability to soothe the disor-
dered minds of his patients as well as to heal their
bodies, and very shortly the elders in our midst
will feel that the practice of medicine has truly
come upon evil days. There zvere giants in those
days, and we glory in the memory of their
achievements but we are living in a present which
shows real progress in the growth of the medical
sciences and we cannot, nor is it wise to try to
stem the tide of this advancement.
Beyond any doubt, the patient of today, for
whose physical defects search is made by the fine
tooth comb of modern clinical and laboratory
methods, is in infinitely safer hands than he was
in the olden days when he was wholly dependent
on one man’s necessarily limited capacity and
more or less well developed intuitions. Just as
the microscope broadened tremendously the scope
of our vision and the depth of our knowledge of
tissues, so the finer machinery of diagnosis has
increased many fold our power to clearly compre-
hend the disease processes underlying any given
syndrome. In a competition between the type-
setting machine and the iourneyman’s stick, be-
tween the jackknife and the lathe, between the
scythe and the automatic binder, there can be only
one result.
A few days ago, a patient in coma was received
into a modern clinic, without history or details of
present attack. In a short time and without harm
to the patient, uremia, high blood-pressure, leu-
kemia, pernicious anemia, and infection were pro-
visionally excluded and pancreatic diabetes with
acidosis was strongly suggested. x\ppropriate
treatment promptly undertaken, tided the patient
over his collapse, and he now faces the hope of
an increased span of life with all that such an
increase may mean to him and his associates. To
us here, such an event is perfectly simple but it is
quite certain that forty, no twenty years ago, in a
similar condition, he would have had to perish, no
matter in what portion of the world he might have
been found, and even now in many doctors’ hands
his case would be hopeless of solution. Examples
of similar purport could be endlessly multiplied.
Tbe high basal metabolic rate which reveals tin-
status, as well as the menace of a toxic adenoma,
the rare parasite in the stool which explains a
mysterious dysentery, the reaction of the serum
which serves to reveal a hidden syphilis, an aty-
pical typhoid, a pancreatic diabetes or an impend-
ing acidosis, the electrocardiogram demonstrating
the true condition of the conducting bundles of
the heart, the roentgen-ray exposing a calculus in
the ureter, a cancer in the colon or an ulcer in the
duodenum, a microscopic section showing the
early malignant growth. The list might be ex-
tended indefinitely.
These procedures are not mere substitutes fur
more careful work on the part of the physician ;
they are distinct additions, often measuring the
difference between success and failure in diag-
nosis and treatment, and occasionally the differ-
ence between life and death itself.
And when death finally does occur, as occur it
must, so long as nature rules, the best type of
laboratory medicine does not cease. The com-
plete post-mortem examination, the careful in-
quiry into the causes of possible failure to make
a proper diagnosis or to give a proper therapy, the
scientific investigation into the correlation and
explanation of clinical phenomena and patho-
genesis of disease, constitute an assurance that
the dead shall not have died in vain.
By each death which may take place while the
patient is under the care of a physician, that phy-
sician is made a debtor to his own best interests,
but what is more important, also to those of his
confreres and humanity in general. This debt can
only be discharged by the most thorough search
possible into the fundamental causes of the con-
ditions which brought about that death, by a crit-
ical analysis of the entire conduct of the case,
with frank acknowledgment of any sins of omis-
sion or commission, and by such publicity as will
bring about a further enlightenment of the pro-
fession and the public with respect to the best
means by which disease may be prevented or diag-
nosed and treated.
The tendency in every branch of commercial
life to eliminate the personal equation and make
each procedure mechanical and automatic, has
spread to other fields and in medicine it some-
times seems, has almost become a plague. Human
nature instinctively approves any custom which
economizes physical or mental energy and at the
same time promises an increased measure of ac-
curacy. Hence, when the earlier laboratory ex-
VoL. XII, No. 12]
Journal of Iowa State Medical Society
505
aniinations demonstrated their reliability and
often amazing value, they inevitably were em-
ployed, not so much as an aid to the standard
methods of diagnosis but as a substitute for these
methods, as a short-cut which made possible the
elimination of many of the laborious efforts of
former times, in which experience, keenness of
perception, memory for details and an inspired
enthusiasm for the work itself were often almost
the sole armamentaria, so far as diagnostic aids
were concerned. The real danger seems to lay,
not in the fact that by the laboratory tests of the
urine obscure conditions in the urinary tract
might become more clearly manifest, but in an
almost certain result of this helpful procedure,
namely the undue dependence by the lazy, the in-
competent and the inexperienced doctor, on the
urine examination alone as the sole means of ar-
riving at the truth. He is asking a machine, quite
efficient within its limits, to bear a load greater
than can be justified on any reasonable grounds.
But this evidence of inherent human frailty
cannot be advanced against the general usefulness
of the laboratory practice of medicine. The abuse
of their opportunities by the mentally and morally
unfit has probably been present since the world
began and will undoubtedly occur under any and
all circumstances as long as the world endures.
Such objections therefore cannot be applied with
any force to the present conditions. The dishon-
est doctor will just as certainly ruin the complex
organization as he has always run riot in his pri-
vate practice.
There is a temptation, however, which is pe-
culiar to those who gather together to treat the
sick and because of its subtle nature and its rather
harmless aspects, the most conscientious may suc-
cumb. I refer to that tendency, which belongs to
all collective organizations, whereby in the very
nature of the work, full responsibility for each in-
dividual case manifestly cannot be shouldered by
each member of the organization. Consequently
responsibility is divided and shared, and, in the
extreme instance, entirely removed. Theoretic-
ally if each did his part and the machinery of the
organization were running perfectly, no trouble
could occur. Practically, it occasionally happens
that through misunderstanding or rigid adherence
to system, the best interests of the patient may
not be fully served. Occasional!)- real neglect of
a given task is excused by the vague hope, that,
in .some way, the organization itself will take care
of what under other circumstances would be an
individual duty. The solution of this difficulty,
which is the greatest that the clinic group may
face, is a fairly simple one.
In the last analysis about 25 per cent of the
legitimate practice of medicine is concerned with
physical ailments, while the remaining 75 per cent,
has to do with the mental status of the jiatient, his
relatives and his friends. I'or this latter moiety
no laboratory procedure can ever re[)lace the skill-
ful, discerning, sympathetic personality of the
physician himself. It becomes (piite clear, there-
fore, that each member of the staff with whom
the patient comes in contact must be perfectly
certain that when that patient is turned over to the
care of some other member, there is a complete
assumption of responsibility, and that in turn his
care will never be given up by any succeeding
member of the group, until there is assurance
that the next one can and will so fulfill his func-
tion as a physician that the full “100 per cent,
practice’’ may be completely realized.
It is not difficult to entertain a friend by seeing
that others help in the best way possible to fill in
his time. Our patients must be treated as our
friends. This altruistic attitude toward the prac-
tice of medicine is just as necessary in the lab-
oratory physician as it is in the members of the
clinical group. Each must practice the art and
the science of medicine to the utmost of hi-,
ability and in no instance must there be omitted
a single measure which might really benefit either
mind or body.
Whether every doctor who works for the pa-
tient’s best interests, shall personally come into
contact with him or his friends, is immaterial.
At times it will be proper for the laboratory con-
sultant to see the patient and when he does, he
should practice medicine just as any other con-
sultant would do.
Perchance after all some of us do not “believe
in” the laboratory practice of medicine and we
have decided arbitrarily, that such an era shall not
be instituted. We argue for the return of the
good old days of the family doctor and the
“golden age” of the general practitioner.
For all such, there is little hope that their de-
sires will, or can, ever be fulfilled. The evolution
of medical education and practice in the unfold-
ing of its growth is as resistless as the progress
of nature in other fields. We are in the presence
of a transition stage in which we may be able to
influence the manner of its development, but we
are unable to change its general direction. The
days of the general practitioner are passing, never
to return again. iMedical education has modified
its product to correspond with the inevitable trend
of events. It makes but little difference whether
these transitions agree with our notions of what
is best, or whether we are bitterly opposed to
506
Journal of Iowa State Medical Society
[December, 1922
them. It would be much more rational, instead
of uselessly expending our energies combatting
changes which must take place in the very na-
ture of things to admit freely that we are rapidly
approaching the time, if it has not indeed already
arrived, when no one physician alone can or
should administer to a diseased individual ; that
such a patient has not had a fair chance unless he
has had the combined services of those adequately
trained in the many branches of medical science.
Admitting this fact and accepting its implications,
we can reap the satisfaction of keeping in step
with the progress of scientific medicine and we
can fulfill our part in assisting the expansion of
what is probably to prove the most glorious period
in all the history of medicine.
INFECTIOUS JAUNDICE
The undersigned is desirous of obtaining informa-
tion regarding the prevalence of infectious jaundice
in your state.
The disease is non-reportable and information re-
garding its prevalence cannot therefore be obtained
from boards of health. I shall be grateful for any
reports of outbreaks which your readers may care to
send me.
George Blumer, M.D.,
195 Church St., New Haven, Conn.
IMPORTANT ANNOUNCEMENT
The medical profession will be interested to learn
that The Abbott Laboratories of Chicago have pur-
chased the Dermatological Research Laboratories of
Philadelphia. This is an advanced step for The
Abbott Laboratories and will give them deserved
recognition among the manufacturers of medicinal
products.
The Dermatological Research Laboratories were
the first in the United States to produce arsphena-
mine during the war; and these laboratories became
well known to the medical profession for their pa-
triotic attitude in developing and manufacturing
medicinal preparations in this country. By this pur-
chase of the “Dri” products, The Abbott Laboratories
inherited their prestige.
The Abbott Laboratories acquired control of the
Dermatological Research Laboratories November 1;
and are continuing to operate them in Philadelphia
under the direction of Dr. Geo. W. Raiziss, head of
the department of chemistry. Orders for “Dri”
products will be promptly filled from the Philadel-
phia laboratories or from their branches or dis-
tributors. For further particulars regarding the pur-
chase of the Dermatological Research Laboratories,
the readers of this Journal are referred to the state-
ment of The Abbott Laboratories on advertising
page vi of this issue, entitled, “Important Announce-
ment to the ^Medical Profession.” .
THE ANNUAL COLLECTION
The 1923 dues for membership in the Iowa State
Medical Society are now due. The component
County Medical Societies should now, or at the
earliest possible time, hold meetings as convenient,
at which time the dues should be paid to the County
Secretary. If it is not possible for a meeting to be
held and the dues collected en masse, the County
Secretary should send out a notice to each member
that collection time is once more at hand, and re-
quest that both county and state dues be paid to him
at once. All dues are payable on or before February
1, after which time a member who has failed to make
his payment, becomes delinquent and is automatic-
ally suspended. Suspension means relinquishment
of all benefits derived from organized medicine,
among which none is of greater importance than
medico-legal protection.
Members should recall that the responsibility of
paying the annual dues naturally falls on each indi-
vidual and not on the officers or the secretary of
the County Society, so see to it that an opportunity
is given at which time the dues may be paid. When
the County Secretary sends you a notice, please be
prompt to return the amount requested so that the
Secretary may make out his roster of membership to
forward, with the dues, to this office at the earliest
possible time.
The right to register at the Annual Session of the
State Society is based entirely on membership, and
the presentation of the annual card is prima facie
evidence that the person holding it is entitled to
register and take part in the meetings.
Knowing that each and every member who reads
this will comply at once, I bespeak a Happy and
Prosperous year for the various component County
Medical Societies and the Iowa State Aledical So-
ciety.
With the Season’s Greetings,
Cordially yours,
Tom B. Throckmorton,
Secretary.
The National Board of Medical Examiners an-
nounces the following dates for its next examina-
tions:
Part I: February 12, 13 and 14, 1923.
Part II: February 15 and 16, 1923.
The fees for these examinations have been con-
tinued at the reduced rate for another year, .\ppli-
cations for these examinations must be forwarded
not later than January 1, 1923. .application blanks
and circulars of information may be obtained from
the Secretary' of the National Board, Dr. J. S. Rod-
man, Medical Arts Building, Philadelphia, Pennsyl-
vania.
VoL. XII, No. 12]
Journal of Iowa State Medical Society
507
Wf)e Journal ol tljc
iotoa ^tate iflebical ^ocietp
D. S. Fairchild, Editor Clinton, Iowa
Publication Committee
D. S. Fairchild Clinton, Iowa
W. L. Bierring Des Moines, Iowa
C. P. Howard Iowa City, Iowa
Trustees
J. W. Cokenower Des Moines, Iowa
T. E. Powers Clarinda, Iowa
W. B. Small Waterloo, Iowa
SUBSCRIPTION $2.75 PER YEAR
Books for review and society notes, to Dr. D. S.
Fairchild, Clinton. All applications and contracts
for advertising to Dr. T. B. Throckmorton, Des
Moines.
Office of Publication, Des Moines, Iowa
Vol. XII December 15, 1922 No. 12
THE QUESTION OF REPRESENTATION OF
THE SECTIONS IN THE HOUSE OF
DELEGATES OF THE AMERICAN
MEDICAL ASSOCIATION
We do not quite understand the fears expressed
in certain quarters of the dangers of the section
delegates voting, no one has stated a concrete ex-
ample of injustice or wrong doing, and we may,
therefore, conclude that the objection rests upon
a theory of organization. There is no doubt that
the association has a perfect right to fix the qual-
ifications of its voting Fellows under the consti-
tution in a constitutional manner. The American
Medical Association is made up of Fellows and
Members and for convenience of operation is di-
vided into sections. Primarily each state is al-
lotted a certain number of delegates based on
membership in state medical societies and these
delegates constitute the House of Delegates who
have the right to vote on all questions submitted
to it. There is no doubt under our theory of gov-
ernment that the right to vote should be limited
to the state delegates who represent the Sovereign
.States. This was the theory of the Constitution
of the United States. It is true that the theory of
“States Rights” have received some shocks, but
the theory of State Sovereignty has never been
changed. It was thought that each section should
be represented in the House of Delegates for the
very obvious reason that the work of the Sections
should be brought to the attention of the House
of Delegates for their advise and direction, but in
our opinion, the right of representation should
not carry with it the right to vote. The section
delegate should bring his report if he has one, and
the right to discuss it and to answer questions,
then his function should cease. He should have
no voice in the House of Delegates beyond the
business of his Section.
His relation should be as it has been proposed
to give Cabinet members the right to appear be-
fore Congress in the interest of their departments.
If it is desirable to have a larger House it should
be by increasing the number of state delegates.
This argument is presented not because we
have objections to the present methods but simply
on Constitutional grounds.
DR. GEORGE H. SIMMONS
The Canadian Medical Association Journal in
the August number publishes from its “Editorial
Chair” an interesting abstract of an address by
Dr. George H. Simmons as President of the In-
stitute of Medicine of Chicago.
The admiration we have for the editor of the
Journal of the American Medical Association is
seconded by the Canadian Journal and it gives us
pleasure to note some of the things Dr. Simmons
says. In 1848 Dr. Oliver Wendall Holmes was
Chairman of a Committee of the American Med-
ical Association on medical literature. The num-
ber of medical journals published in the United
States was twenty, that in 1903 the number had
risen to 230 and has declined to 120 in spite of a
remarkable increase in periodicals devoted solely
to scientific medicine. Dr. Simmons says: “a
distinct change in type of papers appearing in
medical journals today compared with twenty
vears ago. The therapeutic article of the past, re-
plete with favorite prescriptions, often proprie-
tary in character, has given way to scientific con-
tributions on therapeutic methods, on pharma-
cology, on pathology, on etiology, on methods of
diagnosis, on prophylaxis.” It does not appear
that there has been a diminution in the volume of
writing for publication notwithstanding the re-
duction in the number of journals. We are in-
formed that the Journal of the American Medical
Association is now receiving from 1400 to 1500
manuscripts a year, exclusive of the papers sub-
mitted to the sections of the annual meeting. Dr.
Simmons estimates that three-fifths of the manu-
scripts voluntarily offered are returned. There
are of course many reasons for rejection; the
first is lack of space. Some good papers are re-
jected because written in a careless and rambling
manner, due to the absence of plan, the autho>-
508
Journal of Iowa State Medical Society
[December, 1922
goes in a round about way to express his view s
or to reach a point. W'e cannot note all Dr. Sim-
mons says in relation to preparing manuscript for
publication, coming from an editor of vast expe-
rience and great skill the address should be read
by the younger men at least, who have an ambi-
tion to appear in the medical press. It would be
of immense value to prospective writers for medi-
cal journals to write out their cases in an analytic
manner, read over and rewrite until they are sat-
isfied that a clear, understandable, accurate and
logical product is reached. The young man be-
gins wdth his local society and produces a well
planned paper, or he wmites a careless and ram-
bling paper in which perhaps the most important
point is lost. If he begins in this latter manner
of preparing papers it wall become a fixed habit
and disappointments wall come when he appears
before larger and more critical audiences and of-
fers his manuscript for publication.
ETHICS OF FRACTURE CASES
In this number of the Journal is a very sug-
gestive paper by Dr. F. A. Hennessey of New
I lampton under the above title. Dr. Hennessey
IS perfectly correct in his statement that a physi-
cian should never give to the patient of another
doctor an x-ray plate nor should he demonstrate
the plate for obvious reasons. Commercial x-ray
laboratories do not come under this rule because
being commercial are not under ethical control.
To meet just such questions we published in the
July number of the Journal, page 300, Resolutions
adopted by the Radiological Society of North
America adopted at its Annual Meeting in Chi-
cago.
Resolved by the Radiological Society of North
America that it is the sense and judgment of this
society, that all roentgenograms, plates, films, nega-
tive, photographs, tracings or other records of exam-
ination are hereby declared to be the exclusive prop-
erty of the radiologist who made them (or the lab-
oratory where they were made); and be it further
resolved. That the ethics of this society shall be in
full harmony with the principles of medical ethics
of the American Medical Association with the fol-
lowing additions to-wit: The radiologist is hereby
declared to be a consultant in all cases where he is
called upon to examine patients. The radiologist
shall not make known to patients, their relation,
friends or guardians any of the findings or conclu-
sions, nor shall he deliver to them any plates, nega-
tives, films or prints unless expressly requested to do
so by the physician or surgeon who referred the pa-
tient for examination, or is in charge of the case.
This rule of action is absolutely necessary to
prevent dangerous claims for damages even in
cases where the results are good.
With a little juggling the x-ray machine may
make a perfect result appear bad even if there is
no fracture at all. There are certain hospital
x-ray operators wFo are very careless about this
and appear to take delight in exploiting their skill
before the wondering patient. Such practice
should be discouraged.
OFFICIAL BULLETIN OF THE AMERICAN
COLLEGE OF SURGEONS
Boston, October 23. — Hospital service to the pub-
lic in Iowa has shown a marked advance in the past
year, according to the fourth annual report of the
American College of Surgeons released here today.
This report is based on a surv-ey which includes per-
sonal visits to each hospital of fifty beds or over in
the United States and Canada. The following hos-
pitals were given a place on the “approved” list.
Finley Hospital, Dubuque.
*Iowa Congregational Hospital, Des Moines.
Iowa Lutheran Hospital, Des Moines.
Iowa Methodist Hospital, Des Moines.
*Iowa State College Hospital, Ames.
Jennie Edmundson Hospital, Council Bluffs.
*Lutheran Hospital, Sioux City.
Mercy Hospital, Cedar Rapids.
Mercy Hospital, Council Bluffs.
Mercy Hospital, Davenport.
*Mercy Hospital, Des Moines.
*Ottumwa Hospital, Ottumwa.
Park Hospital, Mason City.
St. Francis Hospital, Waterloo.
St. Joseph’s Mercy Hospital, Clinton.
St. Joseph’s Mercy Hospital, Dubuque.
St. Joseph’s Alercy Hospital, Fort Dodge.
St. Joseph’s Mercy Hospital, Mason City.
St. Joseph’s ilercy Hospital, Sioux City.
*St. Joseph’s Mercy Hospital, Waverly.
St. Vincent’s Hospital, Sioux City.
University Hospital, Iowa City.
♦Samaritan Hospital, Sioux City.
The asterisk indicates hospitals which have insti-
tuted measures which insure scientific medical care
to their patients, but which have not realized them to
the fullest extent to date.
“The institutions listed above proved that they are
giving the best of scientific care to their patients,”
declared Dr. Franklin H. Martin, Director-General
of the American College of Surgeons. “Aided by
one of the great educational foundations, we have
carried on actual visits to hospitals, made by trained
medical men who see working conditions as they
are. For the first time this year w'e have surveyed
hospitals of fifty bed capacity and up. These insti-
tutions as well as the larger hospitals show’ a marked
improvement the country over and places low’a in
VOL.XII, No. 12]
Journal of Iowa State Medical Society
509
the forefront of states who are active in medical
progress.
Iowa is to be congratulated on its splendid show-
ing and on the medical men, hospital superintend-
ents, and trustees who have made this advance pos-
sible.”
FOREIGNERS AS ASSISTANTS IN ITALIAN
CLINICS
On the initiative of the Italian League for the Pro-
tection of National Interests, the Faculty of Medi-
cine of the University of Rome has granted foreign
physicians the privilege of entering the Medical and
Surgical Clinics of the University of Rome in the
capacity of assistants without salarj- — a measure
which has been adopted with marked success by the
Universities of France.
These Roman Clinics are under the direction of
the greatest Italian physicians and surgeons.
The following places are available for the next
academic year, which begins in the first week of No-
vember: two places in the surgical clinic; two places
in the medical clinic; two places in the obstetrical
clinic; two places in the dermosyphilopathic clinic;
two places in the clinic for mental and nervous dis-
eases; one place in the orthopaedic clinic.
Foreign physicans are admitted also to the nu-
merous finishing courses offered by the Medical
faculty of Rome.
Applications may be addressed to the president of
the faculty of medicine of the University of Rome
accompanied by a certificate of graduation and a
favorable recommendation from the president of the
applicant’s medical school.
Applications with documents will be received also
by the Italian League for the Protection of National
Interests — (Lega Italiana per La Tutela degli In-
teressi Nazionali) Roma (8) Corso Umberto Primo
No. 101, whi^i will furnish all required information.
THE AMERICAN MEDICAL ASSOCIATION OF
VIENNA
The American Medical Association of Vienna
wishes to have you announce through the columns
of your Journal, the restoration of friendly under-
standings between their organization and the teach-
ing body of the University of Vienna.
A special committee, elected by the association,
after a thorough investigation of the charges of dis-
crimination against Americans, which were reported
by members of our association and published in our
recent memorandum to your Journal, find that the
men, who made the accusations of discrimination
were either unable or unwilling to substantiate these
charges under oath — further the courses in question
were not so called book courses and consequently
were not under the control of the A. M. A. of
Vienna.
It is the sentiment of this association, that the
men of the teaching body of the University of Vienna
have suffered by this unjust criticism.
We further wish to state, that through the efforts
of our special committee, working with a like com-
mittee from the teaching body, sufficient numbers
of book courses in English in all branches may be
had at prices of from $3 to $5 per hour for the
group, takii^ such courses.
We are very glad to announce this return of
friendly relations between the teaching body and
our association and hope that this communication
will be given the same publicity as was given our
former memorandum.
JOHN J. GELZ,
BERNARD KAUFMAN,
WM. WILSON,
Committee.
SOCIETY PROCEEDINGS
Hardin County Medical Society
The Hardin County Medical Society held its reg-
ular meeting at Ackley Wednesday, September 13,
with physicians from Iowa Falls in attendance. The
program included addresses and discussions by phy-
sicians from this county, and invited guests, physi-
cians, from other places. Among other physicians,
the following were on the program: A. F. Byfield
and Frank Novak of Chicago, and Drs. Keyser and
Wahrer of Marshalltown. The program was given
in the afternoon at the Plaza theater, there was a
banquet at 6 p. m. at the Methodist church.
Mills County Medical Society
The Mills County Medical Society held its annual
meeting December 7 at the Iowa Institution for
Feebleminded Children, Glenwood. The county
hospital question was the subject for discussion and
Drs. T. B. Lacey, G. V. Coughlin and M. S. Camp-
bell were appointed as a committee to investigate
the law relative thereto. The following officers were
elected: President, Edgar Christy, Hastings; vice-
president, I. U. Parsons; secretary, M. S. Campbell,
Malvern. It was voted to hold bi-monthly meetings,
and the next meeting of the society will be held at
Malvern, Eebruary 8.
Iowa County Medical Society
The regular meeting of the Iowa County Medical
Society was held in public library of Marengo, No-
vember 29. Dr. F. W. Bush, \'an Horn, read a paper
on Osmosis Applied; Dr. F. O. Blossom, Marengo,
a paper on the Treatment of Typhoid Fever; a re-
port of a case was given by Dr. C. F. Watts, Will-
iamsburg. An interesting discussion followed the
reading of the papers. Dr. J. E. Dvorek, Blairstown,
and Dr. Ciney Rich, Williamsburg, were elected to
510
Journal of Iowa State Medical Society
[December, 1922
membership. Fifteen physicians were in attendance,
and the following officers w^ere elected for the ensu-
ing year: President, W. P. Hutchins, Marengo;
vice-president, H. G. Moershel, Homestead; secre-
tary-treasurer, F. O. Blossom, Marengo. Delegates,
C. F. Watts, Williamsburg and J. C. Ross, North
English.
F. O. B.
Jasper and Marion County Medical Societies
A joint meeting of the Jasper and Clarion County
Medical Societies was held in Pella Thursday, Sep-
tember 28.
The program was as follow's:
Deep X-ray Therapy, Dr. A. L. Yocum, Jr., Chari-
ton. Focal Infection, its Relation to Other Foci,
and Systemic Disease, Dr. James C. Hill, Newton.
Presentation of a Case of Brain Tumor with Clinical
History, Dr. Wm. E. Sanders, Des Moines.
Wortheim Obstetrical Film.
Dinner w'as served at 7 p. m. in the Ladies’ Dor-
mitory of Central College, followed by a most inter-
esting program of music, readings and an admirable
address by Dr. M. J. Hoffman, president of Central
College. Dr. Carl F. Aschenbrenner presided as
toastmaster and was in his usual good form.
The meeting was a success as is evidenced bj^ the
attendance of forty some members of the profession
from Jasper, Marion and neighboring counties, w’hile
seventy-five doctors, their ladies and guests were
present at the dinner.
The physicians of Pella are to be congratulated
for being such admirable hosts.
Dr. C. S. Connell, Sec’y.
Jones County Medical Society
There was a generally attended meeting of the
Jones County Medical Association at Mercy Hospital
on Wednesday evening, September 13. Papers were
read by Dr. H. F. Dolan of Anamosa, Dr. C. G.
Thomas of Monticello and Dr. Hagen of Wyoming.
There w'as a general discussion and also a social side
of the gathering including a supper for the members
served in the hospital dining room.
Pocahontas County Medical Society
The Pocahontas County Medical Society held its
second annual picnic at Fonda, Iowa, August 22,
which was well attended despite the inclement
weather — a great number of visiting doctors being
present from towns outside the county. Many of
the physicians were accompanied by their wives.
The society was honored by the presence of Dr.
Saunders, President of the low^a State Medical So-
ciety; Dr. A. W. Patterson, president of the Society,
presided.
The scientific program was held in the Knights of
Columbus hall. Dr. J. E. Russell of Ft. Dodge read
a well prepared paper on Cause of Obscure Fever in
Children.
Dr. W. W. Brown of Ft. Dodge gave a verj- excel-
lent paper on Appendiceal Abscess. Following the
papers and a session of scientific discussion a social
time was enjoyed.
A. P. Maloney, Secy.
Polk County Medical Society
The regular meeting of the Polk County Medical
Society was held at the Grant Club, September 26,
1922.
Program; Hernias in Infancy and Childhood, F.
W. Fordyce, M.D.; Hyperemesis Gravidarium,
Daniel F. Crowley, M.D.
The Grand Army of the Republic being in session,
members of the medical profession of the organiza-
tion were invited to the dinner and also invited to
participate in the program, among those who ac-
cepted the invitation were Dr. Lewis Stephen Pilcher
of New York, editor of the Annals of Surgery which
is now in its seventy-sixth volume. Dr. Pilcher or-
ganized the Journal, was its first editor and has con-
tinued in that capacity without interruption. Dr.
Pilcher has been in medicine fifty-seven years and
retains a degree of vigor and youthfulness which
promises another fifty-seven years. Thirty-eight
years as editor of one of the great surgical journals
of the world is a remarkable record. Another dis-
tinguished guest was Dr. George F. Harding of
Ohio, father of President Harding. Dr. Harding is
seventy-seven years of age and has been engaged in
the practice of medicine fifty-one years, is still active
in practice. He is at the present time city physician
of his home city but expects to resign at the end of
the year. The writer sat next to Dr. Harding at the
table. Dr. Harding is a friendly guest and free to
talk of professional matters. He assured the writer
that Warren is a good boy but that his other son is
just as good. He started one as a printer and the
other as a doctor. We were left to infer which road
to success and distinction is the best. Dr. Harding
is a vigorous man with apparently many years be-
fore him. His title to membership in the G. A. R.
comes from the fact that he served in the 136th Ohio
Volunteers. It was a hopeful sign when the dis-
tinguished guest was conducted from the hall to at-
tend the governor’s reception by Clyde Herring,
democratic candidate for U. S. Senator from Iowa.
Scott County Medical Society
The Scott County }^Iedical Society resumed its
meetings September 5. The main address was bv
Dr. E. ^1. Eisendrath of Chicago, Kidney Surgery.
Wayne County Medical Society
The Wayne County Medical Society met at the
Majestic Theatre in Seymour on Thursday evening
September 21. Twenty-two physicians were presem
from both within and without Wayne county. The
following officers were elected: President, W. G.
Walker, Corydon; vice-president. Dr. Corbin, Miller-
VoL. XII, No. 12]
Journal of Iowa State Medical Society
511
ton; secretary-treasurer. Dr. G. H. Sollenbarger,
Cor3’don; board of censors. Dr. B. S. Walker, Cory-
don; Dr. G. W. Hinkle, Harvard, and Dr. U. L. Hurt
of Seymour.
Following the election of officers. Prof. O. E.
Klingaman head of the University Extension Depart-
ment of the State University gave an address, ex-
plaining in detail the features of the Shepherd-
Towner Maternity bill. Afterwards a scientific mo-
tion picture of seven reels was shown covering the
subject of “Child Birth,” in its Normal and Ab-
normal Phases. These pictures were of a very high
character, many of them being taken in Vienna, fol-
lowing this a lunch was served.
Woodbury County Medical Society
Dr. Donald McCrae, Jr., of Council Bluffs ad-
dressed the first meeting for the fall and winter
season of the Woodbury County Medical Society at
the West Hotel September 25. His subject was The
Gastric and Duodenal Diagnosis Question.
Dr. McCrae considered the differential diagnoses
of ulcer of the stomach and of the duodenal.
No business was transacted by the society. Dr.
R. F. Bellaire, president, presided and Dr. Victor
Brown, secretary.
Botna Valley Medical Society
The annual meeting of the Botna Valley Medical
Society was held October 5 at Avoca and attended
by a number of local physicians, some of whom had
places on the program. Dr. F. W. Porterfield of
Waterloo, was to have been on the program but he
was prevented b>- illness from attending. The rest
of the program was as follows:
Regular business and election of officers.
Focal Infection, Dr. A. D. Dunn, Omaha, Nebraska.
Ectopic Pregnancy with Case Reports, Dr. R. A.
Becker, Atlantic.
Gastro-Intestinal Disturbances in Children Under
One Year, Dr. Roy Smith, Walnut.
Infant Feeding, a Practical Consideration, Dr.
Fred Moore, Des Moines.
Fractures of the Carpal Scaphoid, with Lantern
Slides, Dr. A. F. Tyler, Omaha, Nebraska.
The Treatment of Head Injuries, Dr. Grant Au-
gustine, Council Bluffs.
Hernia Complications, Dr. C. L. Campbell, At-
lantic.
Iowa X-Ray Club
Members of the Iowa XTRay Club will gather in
Boone Wednesday, October 4, when they will be
guests of Drs. C. A. Noland and Ben T. Whitaker,
local members of the club. Aside from the club
members, the Boone County Medical Association
will be guests as well as other X-ray men of Iowa.
Features of the meeting will be talks b>' Drs.
Louis F. Talle}' of Marshalltown and T. A. Burcham
of Des Moines.
The forenoon will be devoted to clinical cases and
those attending will participate at 12:30 in a luncheon
at Hotel Holst, which will be followed by a business
meeting. It is probable that at this time a reorgani-
zation will be effected.
The afternoon will be occupied with the study of
bone pathology from films furnished by the mem-
bers. The complete program follows:
8:10 a. m. Open house. Dr. Whitaker’s office, 703
Eighth street, and Dr. Noland’s office. First National
Bank building.
10-11:30. Clinical cases. Dr. Whitaker’s office.
11:30-12:30. Clinical cases. Dr. Noland’s office.
12:30. Luncheon Hotel Holst followed by business
session.
2:30. Study of Bone Pathology, Dr. Talley of
Marshalltown leading in the discussion of differen-
tial diagnosis and Dr. Burcham of Des Moines, on
treatment.
AMERICAN UROLOGICAL ASSOCIATION
At the annual meeting of this association held at
Atlantic City, May 26 to 28, officers for the coming
year were elected as follows: President, Dr. Henrj^
L. Sanford of Cleveland; vice-president. Dr. James
A. Gardner of Buffalo; secretary. Dr. Homer G.
Hamer of Indianapolis and treasurer. Dr. James B.
Cross of Buffalo. Rochester, Minnesota, has been
chosen for the place for the next meeting.
DR. HENRY G. LANGWORTHY
Dr. Henry G. Langwmrthy of Dubuque was one of
the active figures at the recent convention of the
Iowa Association of the Deaf, held in that city Au-
gust 22-26. It will be remembered that in 1916 and
1917 Dr. Langworthy as chairman of the Conserva-
tion of Vision and Hearing Committee of the Iowa
State Medical Society raised several hundred dollars
to assist in passing educational legislative laws to
transfer the state school for the deaf at Council
Bluffs from the board of control to the state board
of education, where it rightfully belonged. Up to
that time the deaf school had been under the same
jurisdiction and board which handled the prisons and
asylums of the state. The second bill successfully
passed and placed upon the statute books, as first
published in the columns of this Journal, provided
for the establishment of day-schools for deaf children
up to ten. years of age. After a good deal of work
and the co-operation of the State Medical Society,
much constructive work was done relative to defec-
tive children and of deaf children, which has served
to place Iowa in the front rank of the states of the
country along this line. The doctor was also one of
the chief instruments in organizing the Iowa x\sso-
ciation of Parents of the Deaf at Des Moines, and
through good judgment and ability has helped to pre-
serve the fullest cooperation and harmony on the
512
Journal of Iowa State Medical Society
[December, 1922
part of all friends of the deaf in the state. This co-
operation between the day schools and the state
school, between the Iowa Association of the Deaf,
the Iowa Association of Parents of the Deaf and the
Iowa State Medical Society, has rapidly become
DR. HENRY G. LANGWORTHY
known as the “Iowa Idea” throughout the country,
since it is the term used by the Iowa men themselves,
and first employed by the principal, Dr. J. S. Long of
the Council Bluffs school for the deaf.
Dr. Langworthy at the August convention of the
deaf, presented plans to the Association of the Deaf
for the organization of an endowment fund for the
deaf of the state of $100,000, which plan was unani-
mously adopted by the deaf delegates at their con-
vention. At this meeting the doctor was elected a
life member of the Iowa Association of the Deaf by
the delegates present, an honor not often accorded
a hearing man.
PERSONAL MENTION
Dr. Henry Young of Manson entered the practice
of medicine in Calhoun county, fifty years ago this
month, and invited in the members of the Calhoun
County Medical Society and wives and a few doctors
from outside to celebrate his fiftieth anniversary at
a six o’clock dinner last Thursday afternoon, Septem-
ber 28. A real feast was served, not only a feast of
excellent eats, but also a feast of reminiscences of
other days. .After dinner the following toasts were
given: Legislative Work of Physicians, Dr. D. I.
Townsend, Lohrville. Early Medical Days, Dr, Ellen
Souder, Rockwell City. The Country Doctor, Dr.
C. J. Saunders, Ft. Dodge (president Iowa State
Medical Society), Dr. F. E. Kauffman, president of
the Calhoun County Medical Society, acted as toast-
master, and after the program presented Dr. Young
with a beautiful floor reading lamp as a little token
from the society members, their wives, and friends
of Dr. Young in Manson. Dr. Young responded in
a very feeling and pleasing manner, and gave a beau-
tiful tribute to the practitioners of other days. The
following were present, Drs. Saunders, Evans and
Martin, Ft. Dodge, and the following doctors and
wives, Townsend and Eisenburg, Lohrville; Van
Camp, Somers; Taylor, Pomeroy; Young, Prettyman,
and Hendricks, Manson; Carstensen, Jolley; Beach,
Cooper, Eslick, Van Metre, Souder and Norton,
Rockwell City; Pray, D. W. McCrary, W. E. Mc-
Crary, and Kauffman, Lake City. Besides there were
from Washington, D. C., R. E. McCann, Mrs. Bess
Cox McCann, and the following friends and relatives
from Alanson, Airs. M. H. Cox, Mr. and Mrs. Frank
Mack, Edna, Jean and Mary Howell, Mr. and Airs.
J. W. Young and Henry Young, Sr.
At Iowa City, October 10, a memorial tree was
planted in the station grounds to Dr. Wm. D. Alid-
dleton. Airs. S. C. Plummer (Dr. Aliddleton’s eldest
child), was sponsor. Professor McBride, president
S. U. L, made a short address.
Dr. Fred Alontz will open an office in Lowden. Dr.
Alontz is a graduate from the medical department of
Iowa State University and has had a year’s work in
a Cedar Rapids Hospital.
Dr. L. K. Gundrum of Fontanelle has sold his
practice to Dr. R. D. Russell of Rome, Georgia. Dr.
Russell had two year’s service in the U. S. Army dur-
ing the World War.
E. W. Schumacher, medical masseur and expert in
hydro-electro-therapy recently of Chicago, has lo-
cated in Waverly and opened an office in the Savings
Bank building. He has worked with Dr. Carl Beck
in the North Chicago Hospital, with Dr. Priestley
of Des Aloines and with Dr. Arthur Steindler in
Iowa City. Air. Schumacher is a graduate of King
University, Berlin and of the University of Heidel-
berg.
Dr. H. E. Aleyer has sold his interests in the
Hampton Clinic and closed his work at the Lutheran
Hospital.
Dr. Howard A. Weis, a graduate of the S. U. I.
College of Aledicine in 1918, and a member of the
hospital staff here has located in Davenport, where
he will specialize in obstetrics. Dr. Weis plans to
limit his practice to the treatment of women. Dur-
ing the four years since his graduation he has been
connected with the University Hospital and has
specialized in the branch which he will practice in
Davenport. He has an office at 503 Security build-
ing there.
The home of Dr. F. AI. Shriver on North \ ine
street, Glenwood, was the scene of a merry birthday
gathering on Wednesday afternoon, September 13,
when his comrades of the Civil War gathered in com-
memoration of the seventy-seventh anniversary of
his birth.
Dr. and Airs. Samuel Bailey returned Friday from
a two weeks’ visit at Doctor Bailey’s boyhood home
in Rock Island county, Illinois.
Dr. Alalcolm A. Royal, a graduate of the college
of medicine of the university in 1906, has been ap-
pointed state chairman for Iowa of the American In-
stitute in Homeopathy’s National Clinic Day. Alore
VoL. XII, No. 121
Journal of Iowa State Medical Society
513
than lO.OOU physicians and surgeons are expected to
take part in observing this day.
Dr. Tom B. Tlirockmorton, secretary, and Dr.
h'. E. Sampson, field director, presented the “Iowa
Idea’’ at the Conference of State Secretaries called
by the A. M. A. at Chicago November 17 and 18.
Dr. T. B. Robb of Russell has removed to Chariton.
Dr. R. W. Henderson, who recently located at
Lone Tree taking the place of the late Dr. Day, wdll
locate in Bismark, North Dakota.
Dr. J. I. Clinite of Estherville has moved to Seattle,
Washington, where he will continue in the practice
of medicine.
Major H. R. Reynolds, formerly of Clinton, Iowa,
who served three years in the U. S. Army and who
has for the past two j’ears served at the Veterans’
Public Health Service Hospital No. 67, Kansas City,
Missouri, has been transferred to the Veterans Psy-
chopathic Hospital, Boston, Alassachusetts.
Dr. W. W. Kitson of Des Moines, came to Avoca
recently and closed a deal by which he takes pos-
session of the office of the late Dr. G. A. Spaulding
and will follow the practice of medicine. Dr. Kitson
is a graduate of the medical department of the Iowa
State University at Iowa City. Since graduating he
has been practicing at Des Moines.
Dr. Herbert Pease for the past fifteen years a prac-
ticing physician of Slater, has purchased the office
equipment, library, instruments, etc., of the late Dr.
F. J. Drake, Oelwein.
The following doctors of Iowa county spent some
time during the month of November at the Mayo
Clinic, Jesse Ross, North English, W. P. Hutchins,
Marengo and C. F. Watts, Williamsburg.
HOSPITAL NEWS
Plans for the Upper Iowa conference of the Meth-
odist Church to take over St. Luke’s Hospital of
Cedar Rapids involving the expenditure of $100,000
an addition will be acted on by the conference in
its session at Mason City.
Miss Anne Goetsch, who has been assistant super-
intendent at the Washington County Hospital for
the past several months, has handed in her resigna-
tion to take effect the latter part of this month. Miss
Goetsch is planning to go to Chicago, where she will
take some post graduate work at the Chicago Ly-
ing-in Hospital.
Merej’' Hospital, Clinton, has purchased the mag-
nificent residence known as the Disbrow home ad-
joining the hospital for a nurses’ home.
Laboratory and X-Ray, Mercy Hospital, Dubuque
Fifteen rooms are occupied by the laboratory and
x-ray department. Two large well lighted labora-
tories are equipped with all the appliances and chem-
icals known to clinical medicine, as an aid to diagno-
sis. The x-ray department is provided with four
complete units: one machine being used exclusively
for taking pictures and one machine is devoted en-
tirely to fluoroscopy. The super x-ray machine is used
only for x-ray therapy. The fourth unit is made up
of the latest ultra-violet water-cooled and air-cooled
Burdick lamps used for treatment of skin conditions
and for their bacteriocidal action.
Dr. Johnston is in charge of both the pathological
and the x-ray departments. As assistants he has
four well trained technicians, one record keeper, one
stenographer and three nurses. Dr. Johnston is a
graduate of the University of Michigan where he
spent three years in pathology and two years in
x-ray. The last year was spent very recently as an
instructor under Dr. James Van Zwaluwenberg, one
of the most capable roentgenologists in this countr}'.
This along with the fact that he operated a power
house on St. Anthony Falls in Minneapolis for two
years before attending college, makes him especially
qualified for his work.
A great modern Protestant Hospital to cost not
less than $500,000 will be erected in Sioux City in the
not distant future. It will be under the direction and
receive the constant support of the Methodist Epis-
copal Church, which is becoming extensively en-
gaged in hospitalization throughout the United
States. The new institution will be under the imme-
diate supervision and authority of the northwest
Iowa conference.
Plans for the erection of a $250,000 hospital build-
ing at Twenty-ninth and Douglas streets, Sioux City,
were approved at a meeting of the board of the New
Samaritan Hospital Association.
The new hospital will have from 100 to 125 rooms,
and will be of modern, fireproof construction.
ORPHANS NEED HELP
The Christian Home Orphanage of Council Bluffs,
Iowa, which cares daily for 250 children, and which,
for nearly forty years, has been a haven for thou-
sands of destitute children from all parts of the
country, and which depends wholly upon the volun-
tary contributions of charitable people for its sup-
port, has felt the effects of the close times to such
a degree that unless speedy and liberal help comes,
the work will be seriously injured. In order to
keep its doors open to the hundreds of little ones
that apply annually for food and shelter, the home
is appealing to the public for donations to clear the
work of debt and enable it to meet the calls that
come to it daily. We urge our readers that they
send a donation as liberal as possible to help this
worthy institution. Address The Christian Home
Orphanage, Council Bluffs, Iowa.
514
Journal of Iowa State Medical Society
[December, 1922
OBITUARY
Dr. Ehvood C. Heilman died at his home, in Ida
Grove September 4, 1922 of angina pectoris, age sixty-
six. He was graduated frpm the Medical College of
Ohio in 1877 and was a pupil of Dr. Barthelow, whom
he greatly admired. He came to Ida Grove from
Cedar county, Iowa, and was the first permanent
physician in Ida county and enjoyed the larges.t prac-
tice of any physician of the county. His son, Ernest
S. Heilman, graduated in medicine in 1901 and began
practice with his father; later Dr. Heilman entered the
firm and they secured a building for a hospital and the
firm has operated the same to the present time. Dr.
Heilman was greatly admired by the physicians of
the county and at his burial the older physicians
acted as pall bearers. The inclosed copy of a letter
to his family signed by the physicians of the county
shows the respect and esteem in which he was held
by his fellow practitioners. The Doctor was much
interested in education and was president of the
board of trustees of Morningside College at time of
his death.
Resolutions
To Mrs. E. C. Heilman and Family:
The physicians of Ida county wish to express to
you their deep sympathy in your bereavement. As
fellow workers with Doctor Heilman we fully appre-
ciate the value of his character. The oldest and the
pioneer physician of the county his example has in-
spired in us a better view of life and a broader vision
of the relation of the physician to the community.
The hardships and dangers of the early days seem to
have broadened his sympathies and kindled the spirit
of kindliness that brought comfort and hope to every
home he visited. Dr. A. L. Wright once remarked,
after seeing him examine a patient, that “he was the
best bedside physician he had ever known.” In con-
sultation he always brought confidence to the physi-
cian and settled conviction to the home. His com-
panionship we will all miss. His sense of humor, his
affability and ready wit gave life to our meetings and
wings to our fears. His zeal for community better-
ment broadened his activities and here his true metal
shone to its best advantage. No community wrong
was too small for him to notice or too great to pre-
vent his challenge. He believed firmly in education
and scores of young men and women who were
helped by him to complete their schooling are the
best proof of the earnestness of his belief. His love
of children and respect for the aged stand out as the
true measure of the real physician. His charity for
faults and easy forgetfulness of wrongs endeared
him to us. The path he chose to Calvary was
straight, he dug his own steps, thorns and crumbling
dirt could delay but not prevent his progress to his
goal. His memory we cherish, his example we will
strive to follow. Together we mourn his loss, to-
gether let us hope to emulate his virtues.
The committee follows: G. C. Moorehead, E. S.
Parker, R. B. Armstrong, T. J. Houlihan, E. W.
Bookhart, A. M. Bilby, M. B. Grubb, Glen klillice,
George H. Crane, C. L. Putnam, C. G. Britthauer,
A. H. Bullock, C. S. Stoakes, George A. Hartley.
Benjamin Clarence Stewart was born October 1,
1878, on a hill farm in Switzerland county, Indiana.
He grew to early manhood as a hard-working farmer
boy, attending the district school in the winter
months. By the help and inspiration of an elder sis-
ter the nervous, diffident, though none the less am-
bitious boy was induced to enter the Madison High
School. After graduating he came West to Monona
county, Iowa, and engaged to teach a country school
near Moorhead.
In the fall of 1898 with one brother practicing, an-
other a student, he determined to take up the study
of medicine. This time he needed no persuasion.
Men are sometimes said to be called to a vocation, if
this is so. Dr. Stewart was clearly called to become
a practitioner, bringing to his work an honesty of
purpose, loyalty and energy not too often found.
His college career was not brilliant but satisfactory
to the faculty. He graduated from the S. C. C. M. in
the spring of 1902 and with a certificate as interne in
the Samaritan Home for a period of nearly three
years he was ready to assume the weighty responsi-
bilities of a small-town doctor. Taking his diploma
at face value, he located at Ute, Iowa, for the prac-
tice of medicine and surgery. With the exception of
an interval of some months at Sioux City, Iowa, in
the year of 1918, he labored almost incessantly for
more than eighteen years without proper rest or
mental refreshment.
On March 14, after an unusually hard run of dif-
ficult cases the break came and the instruments he
had so long wielded were laid aside forever. When
the warning came he hastened to the Mayo Clinic,
with which he was so familiar, for advice and treat-
ment but to no avail and on August 12, 1922, passed
to his reward.
Dr. Stewart was united in marriage klay 11, 1904
to Mary A. Scott, a native of Scotland. Mrs. Stewart
was a trained nurse of high ideals, and was not only
a great help to the Doctor in his work but a com-
panion in the truest sense of the word. One child,
a daughter, was born to them.
He was not a man of striking personality nor, as
the world knew him, of pleasing address. In his in-
tense concentration he missed some of the little
amenities of life. Yet he loved men for their worth
and likewise they loved him. He was broad and
general in his reading and interests. He knew how
to hate a crook and respected honor. He was fond
of finding counterparts among those he met and as-
sociated with, to the Uriah Heeps, the Micawbers, the
Falstaffs and Shylocks. It is doubtful though, vivid
and subsequently lurid as his imagination was, if he
ever visualized himself as a character in life’s drama,
doomed to play a part rivaling if not surpassing, in
pathos, that of Jean Valjean.
C. E. Stewart, M.D.
VoL. XII, No. 12]
jouR.NAL OF Iowa State Medjcal Society
515
The death of Dr. Alexander R. Craig removes an
important figure from the executive department of
American medicine. Since 1911 Dr. Craig has served
as a most efficient secretary of the American Medi-
cal Association. Alv^’ays genial in manner he was
never so busy that he could not give information and
advice to all who sought it. In a' great association
composed of so many men, often of divergent views,
it was no small task to maintain a friendly spirit and
prevent discord which was often very near surface.
Dr. Craig’s sense of right was highly developed and
the spirit of justice inherent in his nature had been
highly cultivated by education and environment, and
with a degree of patience rarely seen in men of af-
fairs he became an ideal secretary of one of the most
important bodies of medical men in the world. Be-
hind a most encouraging smile was a firmness of
character that invited the respect of all his associates.
It was the writer’s privilege to serve with him on
several reference committees, particularly on report
of officers at a time when discord threatened and
when a skillful chairman was of vital importance. It
was indeed a fortunate day when Dr. Craig con-
sented to accept the important office of secretary.
Dr. Alexander R. Craig was born in Columbia,
Pennsylvania, July 31, 1868, the son of a physician,
graduated A.B. from Franklin and Marshall College,
Pennsylvania in 1890, the A.M. degree in 1893. He
received his degree of Doctor of Medicine from
University of Pennsylvania in 1893. In 1920 Franklin
and Marshall college conferred the honorary degree
of Doctor of Science. After serving as resident phy-
sician at the Philadelphia Polyclinic Hospital 1893-
1894 he practiced in Philadelphia until 1895 when he
removed to Columbia, Pennsylvania, where he prac-
ticed two years and then returned to Philadelphia
where he practiced until he was elected secretary of
the American Medical Association at the Los An-
geles session, 1911. The election came as a recogni-
tion of his fitness for this high and responsible po-
sition. His skill in directing the sessions of the
House of Delegates was most exemplary. His knowl-
edge of the matters to come before the House and
the arrangement of his papers and notes greatly ex-
pedited the business of the sessions and brought him
the greatest good will of the delegates.
Dr. Craig died of uremic poisoning at Port De-
posit, Maryland, September 2, 1922 at the age of fifty-
four years. His loss to the association will be a se-
vere one and his place will not be easily filled.
Dr. L. E. Park, perhaps the oldest practicing phy-
sician in Marion county, died at his home in Tracy,
Wednesday, October 4, 1922, of angina pectoris, aged
sixty-seven years, nine months and one day.
When about three years’ of age his parents re-
moved to near Attica, Marion county, and about two
years later they again removed to the old farm home,
about five miles west of Lovilia. Monroe county.
Here he grew to manhood, working on the farm,
passing through the country schools, qualifying him-
self as a teacher and following that profession for
eight years, during which time he also attended the
Keokuk College of Physicians and Surgeons at
Keokuk (since merged with the medical department
of Drake University, Des Moines), graduating in the
class of 1880. He also took a post graduate course
in Chicago Polyclinic, Chicago in 1904.
He commenced the practice of medicine in Marys-
ville, with Dr. S. Druitt in 1880 and here on August
2, 1882, he was married to Mary F. Birely. She still
survives him.
He removed to Tracy on April 12, 1882 and here
he continued the practice of medicine until the time
of his death — a period of over forty years, during
which time he was pre-eminently identified with the
professional, business, educational, church, social and
fraternal interests of the community.
His practice extended over a radius of many miles
as a physician of the old school, “family doctor” type,
whose life was devoted to the service of humanity
through his profession. In addition to his regular
practice he was for many years a surgeon for the
Wabash railroad company. He was a member of the
Iowa State Medical Society and of the Marion
County Medical Society, having served the latter as
president a few years ago.
Dr. Theophilus Sprague died September 28, 1922.
Dr. Theophilus Sprague was born at Hilum, Staf-
fordshire, England on November 23, 1846 and was
the son of James and Mary Fulford Sprague. He
came to America in 1854 and to Sheffield in 1857.
His early life was spent on a farm. At the age of
seventeen years he enlisted in Company G, 66th Il-
linois Western Sharpshooters, and participated in the
battle of Snake Creep Gap, Calhoun Ferry, Rome
Crossroads, and marched with Sherman to the sea.
At Raleigh, when Lincoln was assassinated, the 66th
proceeded to Richmond, Fairfax Court House and
Washington to the grand review on May 2, 1865. He
was mustered out July 13, 1865 and read medicine
under Dr. J. L. Morgan at Sheffield. He graduated
from Rush Medical College in 1870 and located in
Russell, Iowa for eight years, returning to Sheffield
in 1878 where he practiced until July of this year.
His “Memoirs of the Civil War” were published as
a serial in the Sheffield Times in the summer of
1920. He was past grand commander of the Grand
Army of the Republic and constantly held office in
the Bureau County Soldiers’ and Sailors’ Association
and in the county, state and national medical so-
cieties.
Dr. Sprague was married to Miss Elizabeth Jones
at Sheffield in 1871. To this union nine children
were born. Mrs. Sprague died August 20, 1896. In
1899 Dr. Sprague was married to Miss Martha Peter-
son, daughter of Mr. and Mrs. John Peterson of
Sheffield.
The Doctor leaves his wife, Martha Peterson
Sprague and his two sons, William and Benjamin.
516
Dr. C. Lester Hall of Kansas City, Missouri, died
at his home in Kansas City, June 10, 1922.
Dr. Hall will be remembered by the older members
of the Western Surgical Association as one of the
most courteous and most distinguished of the orig-
inal members of this association. Dr. Hall graduated
from Jefferson Medical College in 1867. Soon after
graduation he located in Kansas City and became
active in medical affairs of Kansas City and of the
state. He was president of the Missouri State Med-
ical Society in 1895.
Dr. F. R. Mehler of New London, Iowa, died Sep-
tember 24, 1922. Dr. Mehler was born in New Lon-
don Alay 23, 1874, and was the only son of Dr. F. C.
^lehler, an esteemed physician of New London. He
attended the Medical College of Physicians and Sur-
geons at Keokuk and graduated in 1900, after which
he commenced practicing with his father and con-
tinued in his profession until within a short time of
his death. During the war he enlisted and went
as lieutenant with Unit R, overseas, giving sixteen
months of his valuable service in the hospitals in
France.
Dr. A. H. Peters, formerly of Low Moor, died at
Beth-El Hospital, Colorado Springs recently follow-
ing an operation for appendicitis. Dr. Peters was
forty-nine years of age. He was a graduate of
Keokuk Medical College.
Dr. Henry C. Doan, pioneer physician and surgeon
of Humboldt, suffered a stroke of apoplexy, in his
office about midnight Monday night, November 6,
and died within fifteen minutes.
Dr. Doan had attended the Fathers and Sons ban-
quet that evening and appeared in the best of spirits.
Those who sat at the table with him said that he
seemed to be in unusually jolly mood. He returned
to his home, and about midnight answered a call
from a patient. He went to his office to prepare
some medicine, and there suffered the stroke that
ended his life. He felt it coming on, and called Dr.
Arent on the phone, telling him that he had a stroke.
Then he threw open a window and called for help.
Some few minutes later Dr. Arent arrived, but by
that time the stricken man had lost consciousness,
and shortly passed awa}".
Dr. Henry Clay Doan was born on a farm in
Benton county, Iowa, April 10, 1855; his early edu-
cation was received in the public schools, and his
medical course was secured at the University of
Michigan Medical School, Ann Arbor, from which
he graduated in 1884, this same year locating at
Humboldt where he built up a successful practice.
The Doan block of Humboldt is a tribute to his
financial success, and the home with its picturesque
grounds, attributing his love of nature. He was one
of the organizers of the Humboldt County Medical
Society and a member of the Iowa State Medical
[December, 1922
Society, and for years he had been an active member
of the Congregational church.
MARRIAGES
Dr. G. R. Cutter of Council Bluffs and Miss
Josephine Gage were married at Sabula recently. Dr.
Cutter is an interne at the Jennie Edmunson Hos-
pital. Both are graduates from Iowa State Univer-
sity.
Dr. B. Raymond Weston of Mason City and Miss
Dorothy Ellen White of Oskaloosa were married at
Oskaloosa, September 7, 1922.
Dr. J. C. Kassmeyer of East Dubuque and Lillian
May Minges of Dubuque were married at St. Ed-
mond’s Catholic Church at Oak Park, September 9,
1922.
Dr. Howard A. Weis and Miss May Disent were
married in Iowa City August 31, 1922. Dr. Weis is a
graduate of the Iowa University Medical School,
1918. He will locate in Davenport.
THE NEW HOME OF HYNSON, WESTCOTT &
DUNNING OF BALTIMORE
This national drug firm has just erected and oc-
cupied its own building at Charles and Chase streets,
Baltimore. The building is artistic in appearance
and adapted to accommodate the several depart-
ments of their rapidly developing business which
began in a small way in 1889, but has grown to a
million a year, with an organization of 125 people.
Their unique sales department alone comprises nine-
teen men who visit physicians in all parts of the
L^nited States but do not sell goods. Thirty-five of
their products have been accepted by the Council
and are advertised in this Journal. None of their
preparations are offered direct to the public but are
introduced to the medical profession for the use of
physicians and their patients. Mr. H. P. Hynson,
one of the founders, died in 1921; but their growing
business has now been established in new quarters
under the immediate supervision of Messrs. James
W. Westcott and H. A. B. Dunning with a highly
trained force, equipped to meet promptly the de-
mands of the medical profession anywhere and at
all times.
Journal of Iowa State Medical Society
tj|)£ Jfottrnal of tfje
Jfotoa ^tate jHclJital ^tietp
ISSUED MONTHLY
VoL. XII, No. 1
Des Moines, Iowa, January 15, 1922
Single Copies 30 Cents
ttO 'TX
CONTENTS
ORIGINAL ARTICLES
The Passing of the Medical Practitioner,
C. P. Hoicard, A.B., M.D., loua City
SYMPOSIUM OX FOCAL INFECTION
Focal Infections of the Nose and Throat,
L. li'. Dean, M.D., loiva City
Focal Infection of the Mouth, Teeth, Tonsils, and Maxillary
Bones in Relation to Systemic Disease,
Calvin li’. Horned, M.D., Des Moines
Gastrointestinal Infections.
.American Society for the Control of Cancer 21
Physicians Who Located in Iowa in the Period Between 18.50
and 1860 D. S. Fairchild, M.D., F.A.C.S., Clinton 22
EDITORIAL
The Prevention of Puerperal Infection 23
6 Rules Governing the Members of the Iowa State Medical So-
ciety With Reference to the Defense Fund 29
Small-Pox in Kansas City SO
10
SOCIETY PROCEEDINGS
13 Audubon County Jledical Society 31
Austin Flint-Cedar .^'aIley Medical Society 31
15 Chickasaw County Medical Society 32
yi. B. Galloway, M.D., Webster City
Focal Infection in the Genito-urinary Tract.
John S. Mc.dtee, M.D., Council Bluffs
(Continued on Next Page)
Next Annual Session, May 10-11-12, 1922
Entered as second-class matter January 22, 1915, at the post office at Des Moines, Iowa, under the Act of August 24, 1912
Acceptance for mailing at special rate of postage provided for in Section 1103, Act of Oct. 3, 1917, authorized on July 8, 1918
CALCREOSE (calcium creosote) is a mixture containing
in loose chemical combination approximately equal weights
of creosote and lime. It has all the pharmacologic activity
of creosote but has no untoward effects on the stomach;
therefore it may be taken in comparatively large doses for
long periods of time.
In the treatment of acute inflammations of the respira-
tory tract and infections of the gastro-intestinal tract
CALCREOSE has been used with good success.
CALCREOSE can be given in comparatively
large doses for long periods of time without
any objection on the part of the patient.
IV rite for samples and literature
The Maltbie Chemical Company
NEWARK, NEW JERSEY
11
Journal of Iowa State Medical Society
CONTENTS-CONTINUED
SOCIETY PROCEEDINGS— Continued
Clarke County Medical Society 32
Clay County Medical Society 33
Johnson County Medical Society 33
Ringgold County Medical Society 33
Scott County Medical Society 33
Story County Medical Society 33
Van Buren County Medical Society 33
Wapello County Medical Society 33
Southwestern Iowa Medical Society 34
Northwestern Iowa Medical Society 34
Orthopedic Surgeons Meet in Iowa City 34
Iowa State L'niversity News 30
HOSPITAL NEWS 34
MEDICAL NEWS NOTES , 35
personal mention 30
MARRIAGES— OBITUARY 37
MISCELLANEOUS
Dr. F. C. Mahler ~7
The National Health Exposition 27
BOOK REVIEWS 37, Adv. page xvi, xxviii
[gijgjgjgI2j2j2f3f3l3M3M@ISM3MSM3MSI3I3MSISM3l3M3JSMS
And now turn to the advertising pages.
Find therein the firms that can fill
your next order satisfactorily. Give
them the opportunity to prove the
value of their products.
@)313ISM3M313M3JSJSJSJSJSJ3J3EM3J3M3MSM5I3MSJSISI3MiSl
Sherman’s Polyvalent
Vaccines in Respiratory
Infections
A more adequate and rapid immunity is es-
tablished with polyvalent vaccines than from
an infection itself. SHERMAN’S POLYVA-
LENT VACCINES WHEN GIVEN EARLY
IN RESPIRATORY INFECTIONS, rapidly
stimulate the metabolism and defense of the
body with a resultant prompt recovery.
Administered in advanced cases of respira-
tory infections, they usually ameliorate or ab-
breviate the course of the disease. Even when
used as the last desperate expedient they often
reverse unfavorable prognoses. SUCCESSFUL
IMMUNOLOGISTS MAKE INOCULA-
TIONS IN RESPIRATORY INFECTIONS
AT THEIR FIRST CALL.
Hay fever, colds, laryngitis, pharyngitis,
adenitis, catarrh, asthma, bronchitis, pneumonia,
whooping cough and influenza are diseases
amenable to bacterial vaccines.
Sherman’s polyvalent vaccines are dependable
antigens
LABORATORIES OF
G. H. SHERMAN, M. D.
DETROIT, U. S. A.
“Largest producer of stock and autogenous
vaccines”
ANNUAL DUES FOR 1922 ARE NOW DUE
FIVE DOLLARS
Plus the dues of your local Society should be sent or handed to the
Secretary of your County Medical Society before February, 1922.
DO NOT BECOME DELINQUENT
To do so means loss of Membership, loss of Journal, and loss of
the best Medico-Legal Protection.
DR. TOM B. THROCKMORTON
Secretary
When writing to advertisers please mention The Journal of Iowa State Medical Society
W)t J^oumal of tfje
Jfotoa ^tate jHetiital ^wctetp
ISSUED MONTHLY
VoL. XII, No. 2
Des Moines, Iowa, February 15, 1922
Single Copies 30 Cents
$2.75 Per Year
CONTENTS
ORIGINAL ARTICLES
The Relation Between the Specialist and the Profession.
Robert M. Lapsley, M.D., Keokuk 39
The Medical Profession Frank Billings, M.D., Chicago 40
X-Ray Work in Country Practice,
Charles D. Enfield, M.D., Louisville, Ky. 44
Treatment of Diabetes. .Hduin B. IVinnett, M.D., Des Moines 47
The Relation of Hospital Standardization to Obstetrics,
Mary L. Tinley, M.D., Council Bluffs 49
Highmorian Empyema,
Frank L. Secoy, M.S., M.D., Sioux City 50
The Outlook for the Fourth Era of Surgery,
Robert T. Morris, F.A.C.S., Neve York City 53
Pyelitis F. V. Hibbs, M.D., Carroll 54
(Continued (
Unusual Indication for Cesarean Section — Case Report,
A. B. Deering, M.D., F.A.C.S., Boone 58
The Role of the .Alkaline Phosphates in Health and Disease,
J. Henry Dowd, M.D., Buffalo, N. Y. 60
EDITORIAL
Schick Test and Active Immunization Against Diphtheria. ... 63
United States Public Health Service 64
The Trials of Book Publishers 65
Gorgas Memorial Institute of Tropical and Preservative
Medicine 65
Immunologic Experiments with Streptococci from Influenza 66
Incidence of Pneumonia 66
Broncho-Pulmonary Spirochetosis 67
Public No. 97 — 67th Congress S. 1039 68
67th Congress, 1st Session, S. 2764 70
Next Page)
Next Annual Session, May 10-11-13, 1933
Entered as second-class matter January 22, 1915, at the post office at Des Moines, Iowa, under the Act of August 24, 1912
Acceptance for mailing at special rate of postage provided for in Section 1103, Act of Oct. 3, 1917, authorized on July 8, 1918
CALCREOSE (calcium creosote) is a mixture containing
in loose chemical combination approximately equal weights
of creosote and lime. It has all the pharmacologic activity
of creosote but has no untoward effects on the stomach;
therefore it may be taken in comparatively large doses for
long periods of time.
In the treatment of acute inflammations of the respira-
tory tract and infections of the gastro-intestinal tract
CALCREOSE has been used with good success.
CALCREOSE can be given in comparatively
large doses for long periods of time without
any objection on the part of the patient.
IV rite for samples and literature ,
The Maltbie Chemical Company
NEWARK. NEW JERSEY
Journal of Iowa State Medical Society
ii
CONTENTS-CONTINUED
SOCIETY PROCEEDINGS
Allamakee County Medical Society 71
Bremer County Medical Society 71
Butler County Medical Society 71
Calhoun County Medical Society 72
Clinton County Medical Society 72
Cerro Gordo County Medical Society 72
Decatur County Medical Society 72
Des Moines County Medical Society 72
Dubuque County Medical Society 73
Fremont County Medical Society 73
Hancock -Winnebago County Medical Society 73
Henry County Medical Society 73
Ida County Medical Society 74
Jasper County Medical Society 74
Johnson County Medical Society 74
Lee County Medical Society 74
Mahaska County Medical Society 74
Marion County Medical Society 75
Marshall County Medical Society 75
Muscatine County Medical Society 75
Scott County Medical Society 75
Taylor County Medical Society 75
Van Buren County Medical Society 76
Webster County Medical Society 76
Woodbury County Medical Society 76
Boone Medical Society 76
Upper Des Moines Medical Society 76
MEDICAL NEWS NOTES 67
IOWA STATE UNIVERSITY NEWS 68
HOSPITAL NOTES 77
PERSONAL MENTION 78
MARRIAGES AND OBITUARY 79
Milwaukee County Medical Society 79
BOOK REVIEWS 79-80, Adv. Pages xvi, xxviii
New and Non-Official Remedies Adv. Page xxviii
Sherman’s Polyvalent
Vaccines in Respiratory
Infections
A more adequate and rapid immunity is es-
tablished with polyvalent vaccines than from
an infection itself. SHERMAN’S POLYVA-
LENT VACCINES WHEN GIVEN EARLY
IN RESPIRATORY INFECTIONS, rapidly
stimulate the metabolism and defense of the
body w'ith a resultant prompt recovery.
Administered in advanced cases of respira-
tory infections, they usually ameliorate or ab-
breviate the course of the disease. Even when
used as the last desperate expedient they often
reverse unfavorable prognoses. SUCCESSFUL
IMMUNOLOGISTS MAKE INOCULA-
TIONS IN RESPIRATORY INFECTIONS
AT THEIR FIRST CALL.
Hay fever, colds, laryngitis, pharyngitis,
adenitis, catarrh, asthma, bronchitis, pneumonia,
whooping cough and influenza are diseases
amenable to bacterial vaccines.
Sherman’s polyvalent vaccines are dependable
antigens
LABORATORIES OF
G. H. SHERMAN, M. D.
DETROIT, U. S. A.
“Largest producer of stock and autogenous
vaccines”
USE
THE
AND PRESCRIBE
COUNCIL-PASSED
PRODUCTS OF
THE ABBOTT LABORATORIES
New York
Seattle
CHICAGO
San Francisco
See that your druggist is supplied and specify Abbott’s
Los Anseles
ARGYN
A safe and reliable silver colloidal. Con-
tains over 25% silver. Does not irritate.
ACRIFLAVINE
The new Gonocide and antiseptic in con-
venient tablet form. Highly recommended
by many users.
AROMATIC CHLORAZENE POWDER
The Dakin Synthetic Antiseptic in pleas-
ant, palatable form for oral use. Excel-
lent for sore throat and following oral
surgery.
BARBITAL
Introduced as Veronal. Considered safest
and best of available hypnotics.
CINCHOPHEN
Introduced as Atophan. Very effective in
acute rheumatism, arthritis, gout, lum-
bago, neuritis and retention headaches.
CHLORAZENE
Dr. Dakin’s water-soluble synthetic anti-
septic. In tablet and powder form. Highly
germicidal, stable and non-irritating.
SEND FOR LITERATURE
When writing to advertisers please mention The Journal of Iowa State Medical Society
of tf)c
^otua ^tate jHebical ^octetp
ISSUED MONTHLY
VoL. XII, No. 3
Des Moines, Iowa, March 15, 1922
Single Copies 30 Cents
$2.75 Per Year
CONTENTS
ORIGINAL ARTICLES
.\ Clinical Study of Fifty Cases of Pneumothorax,
Willis S. Lemon, M.D., Rochester, Minnesota 81
Arlie L. Barnes, M.D.. Rochester, Minnesota
The .Acute .Abdomen .. Edaxird F. Beeh, M.D., Fort Dodge 89
Chronic Colitis C. B. Luginbulil, M.D., Des Moines 06
Plan of the Medical and Research Service of the Iowa State
Psychopathic Hospital,
Laseson C. Loterey, M.D., lozva City 100
Physicians Who Located in Iowa in the Period between 1850
and 1860 D. S. Fairchild, M.D., F.A.C.S., Clinton 10.3
EDITORIAL
The New Evangelist and Healer Ill
The Pekin Medical College ill
Maternity Bill 112
■A New Hospital at Camp Dodge 112
The Training of Nurses 113
Hospital Standardization 113
Funds for Medical College 116
Memorial to Dr. Sato 116
Group Practice 116
(Continued on Next Page)
Next Annual Session, May 10-11-12, 1922
Entered as second-class matter January 22, 1915, at the post office at Des Moines, Iowa, under the Act of August 24, 1912
Acceptance for mailing at special rate of postage provided for in Section 1103, Act of Oct. 3, 1917, authorized on July 8, 1918
^ ^ ^ REOSOTE and * * ^ * are used internally as intestinal and urin-
ary antiseptics, as stimulant expectorants and in the treatment of tuber-
culosis. Their local irritant actions often interfere with their internal ad-
ministration.” (New and X'onofficial Remedies, 1921, p. 89.)
CALCREOSE is a mixture containing in loose chemical combination ap-
proximately equal weights of creosote and lime (calcium creosotate.)
CALCREOSE administered internally has the same actions and uses as
creosote but does not readily produce gastric distress, nausea and vomiting
even when large quantities are taken for comparatively long periods of time.
C.\LCREOSE may be given in the form of solution or tablets.
IVrite for Samples and Literature
The Maltbie Chemical Co. Newark, New Jersey
11
Journal of Iowa State Medical Society
CONTENTS— CONTINUED
SOCIETY PROCEEDINGS
Clinton County Medical Society
Fremont County Medical Society
Greene County Medical Society.
Hancock-Winnebago County Medical Society
Jasper County Medical Society
Lee County Medical Society
Mahaska County Medical Society
Marshall County Medical Society
Muscatine County Medical Society
Polk County Medical Society...*
Story County Medical Society
Tama County Medical Society
Washington County Medical Society
Keokuk Physicians’ Club
Waterloo City Medical Society
Mississippi Valley Medical Ass’n
IOWA UNIVERSITY NEWS NOTES
MEDICAL NEWS NOTES
HOSPITAL NEWS
PERSONAL MENTION
MARRIAGES
OBITUARY
117
117
117
117
117
118
118
113
118
118
119
119
119
119
119
119
115
116
120
120
122
121
MISCELLANEOUS
Rockefeller Board Aids Brussells University 110
Precautions Against Encephalitis Lethargica liO
American College of Surgeons 113
Hospital Standardization^ Its Inception, Development and
Progress in Five Years 114
Public Health Service Bureau Bulletin 116
Tuberculosis Clinic 120
The St. Louis Meeting of the A. M. A 120
New I^ocal Anesthetic 122
Druggists and Physicians 122
Western Electro-Therapeutic Ass’n Adv. p. xvi
Annual Medical Clinic Adv. p. xvi
BOOK REVIEWS 122-124
Sherman’s Polyvalent
Vaccines in Respiratory
Infections
A more adequate and rapid immunity is es-
tablished with polyvalent vaccines than from
an infection itself. SHERMAN’S POLYVA-
LENT VACCINES WHEN GIVEN EARLY
IN RESPIRATORY INFECTIONS, rapidly
stimulate the metabolism and defense of the
body with a resultant prompt recovery.
Administered in advanced cases of respira-
tory infections, they usually ameliorate or ab-
breviate the course of the disease. Even when
used as the last desperate expedient they often
reverse unfavorable prognoses. SUCCESSFUL
■IMMUNOLOGISTS MAKE INOCULA-
TIONS IN RESPIRATORY INFECTIONS
AT THEIR FIRST CALL.
Hay fever, colds, laryngitis, pharyngitis,
adenitis, catarrh, asthma, bronchitis, pneumonia,
whooping cough and influenza are diseases
amenable to bacterial vaccines.
Sherman’s polyvalent vaccines are dependable
antigens
LABORATORIES OF
G. H. SHERMAN, M. D.
DETROIT, U. S. A.
“Largest producer of stock and autogenous
vaccines”
100% True Gadus Morrhuae
SUPER- REFINED
CLEAR NORWEGIAN
COD IIVER OIL
AioedKjn<>l co^llvrr t>it 4>l •<»-
paaaiogeWiiy an<l ;>u>ur. made
ui BalaGid. (Lof«ten,)
osdet out direxi cuperviaiMt
ocdtafiivcdinoutovps Amoncan
Laboratonea. CoAUmg none
of die oL>^tiaiMbl« feature* or
dnW-bacL* to conun«tn in eare-
WMlymadc inferior (tade*.
It poseeve* a ttrh. nuRy Bator.
i*d«rid<-Jly (talaiftbV. arid mar
be lakeattttb eate by tliotevritn
dehcate dilation* who oidtAw
tJr refute cod liver oJ.
00«B ‘
AiWt*.-— viib Q"* tjaipomJvl
and intPtaia to lablntpooitKiL
CialAnn: — Rc-Julc dote Mewduk*
PR^ouceo et'Ct.uoivcLY
SCOTTfiBOWNE
There are many grades but only one best. The
therapeutic efficiency of cod-liver oil depends largely upon
its purity and palatability — its freedom from admixture
with inferior, carelessly made oils.
Cod-liver oil must be made right from the start
and kept right to assure maximum efficiency.
The & B. PROCESS”
Clear Norwegian (Lofoten) Cod-liver Oil
is made right and stays right. It is the culmination of
half a century of purpose to excel. It is guaranteed 100%
pure oil of true Lofoten Gadus Morrhuae.
It is the efficient oil for the efficient physician.
Stocked by most
^druggists and by
Wholesalers generally.
SCOTT & BOWNE,
Liberal samples will
be sent to any
ohysician upon request.
BLOOMFIELD, N. J.
21-3
When writing to advertisers please mention The Journal of Iowa State Medical Society
3^ournaI of tfje
Jlotoa ^tate jlJleiiital ^mtp
ISSUED MONTHUY
VoL. XII, No. 4
Des Moines, Iowa, April 15, 1922
Single Copies 30 Cents
$2.75 Per Year
Program Number
CONTENTS
Program Seventy-first Annual Session 125
State Society Iowa Medical Women 128
The Des Moines Session 130
Tuberculosis Clinic - 130
ORIGINAL ARTICLES
Diseases of the Blood-vessels as Seen in the Eye,
Edivard Jackson, M.D., Denver, Colorado 131
Retinal Changes in Cardio-Vascular and Renal Diseases,
James E. Reeder, M.D., Sioux City 136
Pneumococcus Peritonitis,
Victor F. Marshall, B.S., M.D., F.A.C.S., Appleton, IVis, 138
(Continued
Diagnosis and Treatment of Infantile Paralysis,
Arch F. O’Donoghue, M.D., Sioux City 141
Acute Infections of the Abdomen,
D. Ward, M.D., Oelwein 143
The Significance of Sacro-Coccygeal Dermoids in Relation to
A. P. Stoner, M.D., F.A.C.S., Des Moines 145
Physicians Who Located in Iowa in the Period between 1850
and 1860 D. S. Fairchild, M.D., F.A.C.S., Clinton 147
Next Page)
Next Annual Sfssion, May 10-11-12, 1922
Entered as second-class matter January 22, 1915, at the post office at Des Moines, Iowa, under the Act of August 24, 1912
Acceptance for mailing at special rate of postage provided for in Section 1103, Act of Oct. 3, 1917, authorized on July 8, 1918
t t
^ ^^REOSOTE and * * * * are used internally as intestinal and urin-
ary antiseptics, as stimulant expectorants and in the treatment of tuber-
culosis. Their local irritant actions often interfere with their internal ad-
ministration.” (New and Nonofficial Remedies, 1921, p. 89.)
CALCREOSE is a mixture containing in loose chemical combination ap-
proximately equal weights of creosote and lime (calcium creosotate.)
CALCREOSE administered internally has the same actions and uses as
creosote but does not readily produce gastric distress, nausea and vomiting
even when large quantities are taken for comparatively long periods of time.
CALCREOSE may be given in the form of solution or tablets.
fV rite for Samples and Literature
The Maltbie Chemical Co. Newark, New Jersey |
— — 4-
11
Journal of Iowa State Medical Society
CONTENTS— CONTINUED
EDITORIAL
Iowa State Medical Society 151
British Medical Association 152
Early British Medical Journals 152
SOCIETY PROCEEDINGS
Boone County Medical Society 160
Calhoun County Medical Society 160
Cerro Gordo County Medical Society 160
Davis County Medical Society 16u
Hamilton County Medical Society 160
Linn County Medical Society 160
Mahaska County Medical Society 160
Pottawattamie County Medical Society 160
Wapello County Medical Society 161
Scott County Medical Society 161
Iowa Clinical Surgical Society 161
IOWA. STATE UNIVERSITY NEWS NOTES 153
MEDICAL NEWS NOTES 159
HOSPITAL NEWS 162
PERSONAL MENTION 163
OBITUARY 164
MISCELLANEOUS
Arkansas Medical Society Home-Coming
Canada Medical Association
Association of Japanese Medical Men
The Hospital Survey of the College
The Standardization Program of the American College of
Surgeons 1?5
Division of Fees 157
Dead and Wounded in German Empire in JVorld War 157
Dangers to X-Ray Operators 157
Pay Clinics 15 7
Increased Cost of Liability Insurance 158
New York Hospitals 158
Life of College-Bred Women 158
The Pacific Northwest Medical Association 158
American Physicians Honored 158
Advertising in ^Medical Journals 158
Chicago Physicians Honored 158
Losses in the Profession in Italy During the War 159
BOOK REVIEWS 167
Sherman’s Polyvalent
Vaccines in Respiratory
Infections
A more adequate and rapid immunity is es-
tablished with polyvalent vaccines than from
an infection itself. SHERMAN’S POLYVA-
LENT VACCINES WHEN GIVEN EARLY
IN RESPIRATORY INFECTIONS, rapidly
stimulate the metabolism and defense of the
body with a resultant prompt recovery.
Administered in advanced cases of respira-
tory infections, they usually ameliorate or ab-
breviate the course of the disease. Even when
used as the last desperate expedient they often
reverse unfavorable prognoses. SUCCESSFUL
IMMUNOLOGISTS MAKE INOCULA-
TIONS IN RESPIRATORY INFECTIONS
AT THEIR FIRST CALL.
Hay fever, colds, laryngitis, pharyngitis,
adenitis, catarrh, asthma, bronchitis, pneumonia,
whooping cough and influenza are diseases
amenable to bacterial vaccines.
Sherman’s polyvalent vaccines are dependable
antigens
LABORATORIES OF
G. H. SHERMAN, M. D.
DETROIT, U. S. A.
“Largest producer of stock and autogenous
vaccines”
❖ *
Preserve the Present for the Future
TOWNSEND
The finest photographic studio
ifi the Middle West
1009 LOCUST STREET
ONE BLOCK FROM FORT DES MOINES HOTEL
When writing to advertisers please menrion The Journal of Iowa St^te Medical Society
^ . V-
Jfountal of tfje
jotoa ^tate jHebital ^wcictp
ISSUED MONTHLY
VoL. XII, No. 5
Des Moines, Iowa, May 15, 1922
Single Copies 30 Cents
$2.75 Per Year
CONTENTS
ORIGINAL ARTICLES
Oration in Surgery — Do We Progress?
W. A. Rohlf, M.D., Waverly 169
The Relation that Exists Between Hypertension, Myocarditis,
and Nephritis Henry A. Christian, M.D., Boston 17T
Luminal in the Treatment of Epilepsy: Preliminary Report,
M. Nelson Voldeng, M.D., Woodward 175
Conservative Surgery of the Female Pelvic Organs,
A. G. Shellito, M.D., Independence 179
Combined Anesthesia,
Charles Ryan, M.D., F.A.C.S., Des Moines 131
The Educational Phase of Public Health, Jeannette F.
Throckmorton, Ph.B., A.M., M.D., F.A.C.P., Chariton 134
Tumors Involving the Oral Cavity, Upper Respiratory
Passages, and Ears, and Some Observations Following
the Use of Radium,
Margaret Armstrong, M.D., Iowa City 187
EDITORIAL
Some Dissatisfaction with National Health Insurance in
England 194
Physical Census of the Male Population 194
Pellagra in the Southern States 196
(Continued
Medicine and Politics 196
Hospital Standardization from the Viewpoint of the Hospital
Superintendent 197
Field Secretary — A. M. A 198
Next Page)
Entered as second-class matter January 22, 1915, at the post office at Des Moines, Iowa, under the Act of August 24, 1912
Acceptance for mailing at special rate of postage provided for in Section 1103, Act of Oct. 3, 1917, authorized on July 8, 1918
CALCIUM IN INTESTINAL TUBERCULOSIS
“The administration of calcium chlorid in tuberculous diarrhea is, we
believe, based on empiricism, but of its good effects there are at present
many undeniable examples. * * * have used calcium chlorid in
no sense as a curative agent, but merely as a palliative in an attempt to
control the distressing symptoms of pain and diarrhea.” — P. H. Ringer
and C. I. Mipor, Am. Rev. Tuberc. 5:876 (Jan.) 1922.
CALCREOSE (calcium creosotate) is a mixture containing in loose
chemical combination approximately equal parts of creosote and lime.
CALCREOSE has the same actions and uses as creosote but is free
from its untoward effects on the stomach. Creosote is used as an in-
testinal antiseptic.
rite for Samples and Literature %
The Maltbie Chemical Company
NEWARK, NEW JERSEY
11
Journal of Iowa State Medical Society
CONTENTS— CONTINUED
society proceedings
Cerro Gordo County Medical Society 201
Dubuque County Medical Society 201
Kossuth County Medical Society 201
Story County Medical Society 201
Taylor County Medical Society 201
Webster County Medical Society 202
Shenandoah City Medical Society 202
IOWA STATE UNIVERSITY NEWS 19G
medical NEWS NOTES 200
HOSPITAL NEWS 202
PERSONAL MENTION 203
OBITUARY 203
MISCELLANEOUS
Needs of Army Medical Department 193
New Organism Akin to Botulinus 193
Election of Editors of Special Journals Published by A.
M. A 198
Question of Damages Involved in Failure to Use X-Ray in
Fracture of Femur 199
Laboratory Workers Contract Tularaemia 190
The Treatment of Carbon Monoxide Poisoning 200
BOOK REVIEWS 204, Adv. Page xvi
•i j.
Sherman’s Polyvalent
Vaceines in Respiratory'
Infections
A more adequate and rapid immunity is es-
tablished with polyvalent vaccines than from
an infection itself. SHERMAN’S POLYVA-
LENT VACCINES WHEN GIVEN EARLY
IN RESPIRATORY INFECTIONS, rapidly
stimulate the metabolism and defense of the
body with a resultant prompt recovery.
Administered in advanced cases of respira-
tory infections, they usually ameliorate or ab-
breviate the course of the disease. Even when
used as the last desperate expedient they often
reverse unfavorable prognoses. SUCCESSFUL
IMMUNOLOGISTS MAKE INOCULA-
TIONS IN RESPIRATORY INFECTIONS
AT THEIR FIRST CALL.
Hay fever, colds, laryngitis, pharyngitis,
adenitis, catarrh, asthma, bronchitis, pneumonia,
whooping cough and influenza are diseases
amenable to bacterial vaccines.
Sherman’s polyvalent vaccines are dependable
antigens
LABORATORIES OF
G. H. SHERMAN, M. D.
DETROIT, U. S. A.
“Largest producer of stock and autogenous
■ vaccines”
When writing to advertisers please mention The Journal of Iowa State Medical Society
tJlje Jfoumal of tfje
jlotoa ^tate J^ebtcal ^octetp
ISSUKO SIUNTHL^
VoL. XII, No. 6
Des IMoines, Iowa, June 15, 1922
CONTENTS
Single Copies 30 Cents
$2.75 Per Year
^ ORIGINAL ARTICLES
Medical Problems in Iowa,
A. M. Pond, M.D., F.A.C.S., Dubuque 205
Types of Severe Anemia — With Especial Reference to Sec-
ondary Hypoplastic Anemia,
Alfred Stengel, M.D., Philadelphia 208
The Present Status of the Treatment of Pernicious Anemia,
Philip B. McLaughlin, M.D., F.A.C.S., Sioux City 214
The Control of Hemorrhage in the Tonsil Operation,
Fred IV. Bailey, M.S., M.D., F.A.C.S., Cedar Rapids 222
Some Determining Factors in Nasal Sinus Diseases,
G. F. Harkness, M.S., M.D., F.A.C.S., Davenport 224
Combined Anesthesia,
Charles Ryan, M.D., F.A.C.S., Des Moines 230
EDITORIAL
Seventy-First Annual Session Iowa State Medical Society. . 232
Ray Lyman Wilbur, M.D., President-Elect American Medi-
cal Association 234
Officers Iowa State Medical Society 234
Pernicious Anemia: A Study of One Hundred Twenty-
Seven Cases F. /. Rohner, M.D., Iowa City 216
(Continued on Next Page)
Entered as second-class matter January 22, 1915, at the post office at Des Moines, Iowa, under the Act of August 24, 1912
Acceptance for mailing at special rate of postage provided for in Section 1103, Act of Oct. 3, 1917, authorized on July 8, 1918
CALCIUM IN INTESTINAL TUBERCULOSIS
* “The administration of calcium chlorid in tuberculous diarrhea is, we
believe, based on empiricism, but of its good effects there are at present
many undeniable examples. * * * \\7g have used calcium chlorid in
no sense as a curative agent, but merely as a palliative in an attempt to
control the distressing symptoms of pain and diarrhea.” — P. H. Ringer
and C. I. Minor, Am. Rev. Tuberc. 5:876 (Jan.) 1922.
CALCREOSE (calcium creosotate) is a mixture containing in loose
chemical combination approximately equal parts of creosote and lime.
CALCREOSE has the same actions and uses as creosote but is free
from its untoward effects on the stomach. Creosote is used as an in-
testinal antiseptic.
IV rite for Samples and Literature
The Maltbie Chemical Company
NEWARK, NEW JERSEY
Journal of Iowa State Medical Society
CONTENTS— CONTINUED
SOCIETY PROCEEDINGS
Cerro Gordo County Medical Society
Johnson County Medical Society
Plymouth County Medical Society
Marion County Medical Society
Tama County Medical Society
Wapello County Medical Society 230
Southwestern Iowa Medical Society 23i!
Northwestern Iowa Medical Society' 236
Iowa and Illinois Central District Medical Society 237
Tri-State Medical Association of Iowa, Illinois and Wis-
consin 237
Southern Minnesota Medical Association 237
IOWA STATE UNIVERSITY NEWS NOTES 234
MEDICAL NEWS NOTES 235
WE BELIEVE
^HE Medical Profession will be
pleased to know that for the past
nine months the Sherman ten mil. vial
has been filled to contain I2V2 milliliters
of vaccine.
In the future this package will be
known as a 12V2 niil. vial and will sell
at $2.00, the price of the former 1 0 mil.
vial.
HOSPITAL NOTES 237
PERSONAL MENTION 23S
OBITUARY 240
MISCELLANEOUS
National Board of Medical Examiners 23i
American Society for the Control of Cancer 231
Dr. Eugene A. Crouse, Grundy Center 239
Resolutions of Tama County Medical Society 242
BOOK REVIEWS Adv. Page xiv J[
This is equivalent to a price of $ 1 .60
on a ten mil. basis and is an increase of
25% in the quantity of vaccine.
Bacteriological Laboratories of
G. H. SHERMAN, M. D.
DETROIT, MICH.
}.
npll'nalli
Our Manufacturing Laboratories at
Bloomfield, N. J.
Here's where genuine Atophan is
manufactured by a special pro-
cess completely precluding the
possibility of unpleasant empy-
reumatic admixtures.
This means a still further improved
Atophan for your cases of Rheuma-
tism, Gout, Neuralgia, Neuritis, Sci-
atica, Lumbago and “Retention”
Headaches.
Ample trial quantity and literature
from
SCHERING & GLATZ, Inc.
150-1S2 Maiden Lane - NEW YORK
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Journal of Iowa State Medical Society
XXV
Group Allergens
Squibb
The importance of testing patients with a large
number of different proteins has emphasized the need
for combining into a series of group allergens, a num-
ber of the closely allied individual ones.
In cooperation with Dr. \V. W. Duke, a series
of 27 such groups have been developed for diagnos-
tic purposes, each mixture, with but few exceptions,
containing five allergens, and the endeavor has been
to group them on the basis of actual clinical obser-
vation.
These group mixtures materially lessen the number of tests required and makes
it possible to test each patient with a larger number of proteins with less inconvenience
and in shorter time than would otherwise be involved.
The following groups are now available:
Vegetables (5)
Meats (2)
Condiments
Feathers
Fruits (3)
Fowl
Beverages
Pollens (2)
Nuts (2)
Fish (2)
Egg and Milk
Bacterial (3)
Cereals
Mollusks (2)
Hair and
Dander (2)
Thyroxin
Prepared Under License of the
University of Minnesota.
Pure Crystalline Thyroxin is the physiolog-
ically active constituent of the thyroid gland; a
compound of definite and known chemical com-
position containing 65% of iodine, organically
combined as an integral part of the molecule.
Fifteen grains of desiccated thyroid pre-
pared under favorable conditions contains ap-
proximately 1 64 grain of Thyroxin.
Thyroxin is marketed in two forms — Tablets containing the partially purified
sodium salt for oral administration, and the Pure Crystalline Thyroxin for intravenous
administration in cases where the product is not absorbed quantitatively when given by
mouth.
Complete information on request
E R: Squibb ^Sons
MANUIACnjRING CHEMISTS TO THE MEDICAL PROJXSSIQN SINCE 1858
When writing to advertisers please mention The Journal of Iowa State Medical Society
XXVI
Journal of Iowa State Medical Society
NEARLY THREE MILLION DOLLARS
Do You Realize How Much That Is?
If you had to count three millions at the rate of one hundred per minute (working
Union hours — 8 hours a day — days a week) you would have steady work for
over ELEVEN WEEKS.
just counting — counting — counting — no time off for anything.
THREE IMILLION DOLLARS is just about the amount of OUR BUSINESS dur-
ing the last eleven years with the AIEDICAL PROFESSION.
There must be a REASON — There IS a reason — in fact there are TWO REASONS
for this large volume.
Quality and Satisfaction
OMAHA
SURGICAL SUPPLIES
ST. LOUIS
-7,
r~
The Nebrsiska Laboratory
354 Brandeis Theatre Bldg.
OMAHA
Tissue Examinations
Bacteriological Examinations
Colloidal Gold Reactions
Alkali Reserve Determinations
Dark Field Examination
We will be glad to advise with you concerning any laboratory problem
Sterile Containers sent on request
Wassermann Tests
Autogenous Vaccines
Blood Chemistry
Urine Chemistry
Blood Counts
o
E. T. MANNING, B. S., M. D., Mgr.
□h
a
imiipiUJlIHiiiiiMiiiiiiimiiiiiHuiiii
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Journal of Iowa State Medical Society
xxvn
Biological Products that have made possible the
Eradication of Diphtheria as an Epidemic Disease
The Diphtheria Group
Squibb Biological Laboratories
Schick Test Squibb
1 •
• @
I
CoDtrol lojecting Toxin The Reaction
Schick Test Squibb
A reliable diagnostic test for susceptibility to diphtheria. A safe
guide in determining the need of Toxin- Antitoxin immunization.
Diphtheria Toxin- Antitoxin Mixture Squibb
Establishes an active immunity against diphtheria lasting three years
or longer. As easy to administer as the typhoid vaccine.
Diphtheria Antitoxin Squibb
Isotonic with the blood. Small bulk with a minimum of solids in-
sures rapid absorption and lessens the dangers of severe anaphylactic
reaction.
Other Seasonable Biologicals
SMALLPOX VACCINE, INFLUENZA VACCINES,
ANTI-PNEUMOCOCCIC SERUM and VACCINE.
Complete Information on Request,
L R: Squibb fit Sons
MANUBtCniRING CHEMISTS TO THE MEDICAL PROFESSION SINCE I85S
nkw York
When writing to advertisers please mention The Journal of Iowa State Medical Society
xxviii
Journal of Iowa State Medical Society
NEARLY THREE MILLION DOLLARS
Do You Realize How Much That Is?
If you had to count three millions at the rate of one hundred per minute (working
Union hours — 8 hours a day — days a week) you would have steady work for
over ELEVEN WEEKS.
just counting — counting — counting — no time off for anything.
THREE IMILLION DOLLARS is just about the amount of OUR BUSINESS dur-
ing the last eleven years with the IMEDICAL PROFESSION.
There must be a REASON — There IS a reason — in fact there are TWO REASONS
for this large volume. "V
Quality and Satisfaction
OMAHA
SURGICAL SUPPLIES
ST. LOUIS
O
The NebrEiska Laboratory
354 Brandeis Theatre Bldg.
OMAHA
Wassermann Tests
Autogenous Vaccines
Blood Chemistry
Urine Chemistry
Blood Counts
Tissue Examinations
Bacteriological Examinations
Colloidal Gold Reactions
Alkali Reserve Determinations
Dark Field Examination
W e will be glad to advise with you concerning any laboratory problem
Sterile Containers sent on request
E. T. MANNING, B. S., M. D., Mgr.
&
Q
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louKNAL OF Iowa State Medical Society
XXXV
ANTI-PNEUMOCOCCIC SERUM SQUIBB LEUCOCYTE EXTRACT SQUIBB
(Type 1) (From the Horse)
The contract of the State Boar(i of Health makes
Squibb Biologicals the only official serums and
vaccines in Iowa
For the
V^enereal Campaign
Solargentum
Protargentum
Prophylactic Ointment
Note Special
DIPHTHERIA ANTITOXIN SQUIBB
1.000 Units Packages $0.50
3.000 Units Packages 1.25
5.000 Units Packages 1.80
10,000 Units Packages 8.85
10,000 Units Packages 8.70
SMALLPOX VACCINE SQUIBB
Packages of 10 Capillar; Tubes $0.80
Packages of 5 Capillar; Tubes 40
Contract Prices
TETANUS ANTITOXIN SQUIBB
1,500 Units Packages $1.67
8.000 Units Packages 2.87
6.000 Units Packages 4.00
TYPHOID VACCINE SQUIBB
1 Immunization Treatment (3 s;ringes) $0.86
1 Immunization Treatment (3 Ampuls) . . .28
1 30-Ampul Package (Hospital) 3.60
Distributors in Every County
General Distributors
Iowa State Board of Health, Des Moines, Iowa
E. R. Squibb & Sons, 323 West Lake Street, Chicago, III.
E R_ Sq.uibb h. Sons .New York
M A ISI U F ACTU R I nC CHEMISTS TO THE MEDICAL PROFESSION SINCE 18 56
When writing to advertisers please mention The Journal of Iowa State Medical Societ;
XXXVl
Journal of Iowa State Medical Society
NEARLY THREE MILLION DOLLARS
Do You Realize How Much That Is?
If you had to count three millions at the rate of one hundred per minute (working
Union hours — 8 hours a day — 5j4 days a week) you would have steady work for
over ELE^^EX WEEKS.
just counting — counting — counting — no time off for anything.
THREE MILLION DOLLARS is just about the amount of OUR BUSINESS dur-
ing the last eleven years with the IMEDICAL PROFESSION.
There must be a REASON — There IS a reason — in fact there are TWO REASONS
for this large volume.
Quality and Satisfaction
OMAHA
SURGICAL SUPPLIES
ST. LOUIS
The Nebreiska Laboratory
3S4 Brandeis Theatre Bldg.
Wassermann Tests
Autogenous Vaccines
Blood Chemistry
Urine Chemistry
Blood Counts
We will be glad to advise with you concerning any laboratory problem
Sterile Containers sent on request
OMAHA
Tissue Examinations
Bacteriological Examinations
Colloidal Gold Reactions
Alkali Reserve Determinations
Dark Field Examination
E. T. MANNING, B. S., M. D., Mgr.
READ THE ADVERTISING PAGES
Journal of Iowa State Medical Society
xxvii
Biological Products that have made possible the
Eradication of Diphtheria as an Epidemic Disease
The Diphtheria Group
Squibb Biological Laboratories
Schick Test Squibb
CoDtrol Injecting Toxin The Reaction
Schick Test Squibb
A reliable diagnostic test for susceptibility to diphtheria. A safe
guide in determining the need of Toxin-Antitoxin immunization.
Diphtheria Toxin- Antitoxin Mixture Squibb
Establishes an active immunity against diphtheria lasting three years
or longer. As easy to administer as the typhoid vaccine.
Diphtheria Antitoxin Squibb
Isotonic with the hlood. Small bulk with a minimum of solids in-
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Other Seasonable Biologicals
SMALLPOX VACCINE, INFLUENZA VACCINES,
ANTI-PNEUMOCOCCIC SERUM and VACCINE.
Complete Information on Request,
E*R: Squibb SlSons
MANUBVCrURJNG CHLHISIS TO THE MEDICAL PROFESSION SINCE 1858
Ne,w York
When writing to advertisers please mention The Journal of Iowa State Medical Society
xxviii Journal of Iowa State Medical Society
There is **Blue Sky** and Water” in merchandise
as well as in stocks and shares. The country is full of merchan-
dise of all kinds which is left over from war time when “any-
thing was acceptable”. Wise Buyers will confine their
dealings to:
HOUSES OF REPUTE-those they
know have a reputation to sustain.
A Reliable House handles only Reliable Merchandise —
don’t buy from a house you do not know. No matter what
the smooth salesman tells you —
Price Depends on Quality
You cannot get “Something for Nothing”.
The W. G. CLEVELAND COMPANY, inc.
OMAHA and SAINT LOUIS
(A Surgical House since 1891 — thirty years continuous btisiness with Physicians and Hospitals)
Q
NiiiiiniHiMMitiiiiiint
O
The Nebraska Laboratory
354- Brandeis Theatre Bldg.
OMAHA
Wassermann Tests
Autogenous Vaccines
Blood Chemistry
Urine Chemistry
Blood Counts
Tissue Examinations
Bacteriological Examinations
Colloidal Gold Reactions
Alkali Reserve Determinations
Dark Field Examination
We will be glad*to advise with you concerning any laboratory problem
Sterile Containers sent on request
E. T. MANNING, B. S., M. D., Mgr.
&
Q
When writing to advertisers please mention The Journal of Iowa State Medical Society
Journal of Iowa State Medical Society
XXIX
'J^HE complicated technic incident
to the preparation of solutions of
Arsphenamine with the attendant dan-
ger of improper all^alization as well
as the rapidity with which the Ars-
phenamine oxidizes and forms toxic
compounds during the preparation of
the solution, make it apparent that the
widespread use of this product is de-
pendent upon the development of a
safe and ready-to-use solution.
The Squibb Laboratories therefore
take pleasure in announcing that they
have ready for distribution
Solution Arsphenamine
Squibb
Prepared according to the process devised by Dr. Otto Lowy; licensed by the
U. S. Public Health Service and approved by the Council on
Pharmacy and Chemistry of the American Medical Association.
READY FOR IMMEDIATE USE.
Solution Arsphenamine Squibb offers the advantages o( ac-
curacy in preparation, perfect alkalization, and safety in use.
It avoids the danger of oxidation with the consequent formation of
toxic oxidation products, and it eliminates the necessity for costly appara-
tus and the loss of time spent in preparing solutions.
Solution Arsphenamine Squibb is a scientifically prepared solu-
tion of Arsphenamine. It is in no sense a substitute for Arsphenamine.
Solution Arsphenamine Squibb is marketed in 80 Cc. and
120 Cc. ampuls with all necessary attachments, ready for administration.
E R: Squibb & Sonts.New York
MAMUFACTURING CU£M1STS TO THC.MEDICAL PROFESSION.S1NCE laSSU
When writing to advertisers please mention The Journal of Iowa State Medical Society
I
XXX
Journal 6f Iowa State Medical Society
D
T
HERE is **Blue Sky** and **Water** in merchandise
as well as in stocks and shares. The country is full of merchan-
dise of all kinds which is left over from war time when “any-
thing was acceptable’’. Wise Buyers will confine their
dealings to:
HOUSES OF REPUTE-those they
know have a reputation to sustain.
A Reliable House handles only Reliable Merchandise —
don*t buy from a house you do not know. No matter what
the smooth salesman tells you —
Price Depends on Quality
You cannot get “Something for Nothing ’.
The W. G. CLEVELAND COMPANY, inc.
OMAHA and SAINT LOUIS
(A Surgical House since 1891 — thirty years continuous business -with Physicians and Hospitals)
o
■iiiuiiHiiiiiimmm
iiiiiliiiHiiiHiiNiHiiiiriiiiiiiiiriiiiiiiiiiiiiiiiHiiii
The Nebreiska Laboratory
354 Brandeis Theatre Bldg.
OMAHA
Wassermann Tests
Autogenous Vaccines
Blood Chemistry
Urine Chemistry
Blood Counts
Tissue Examinations
Bacteriological Examinations
Colloidal Gold Reactions
Alkali Reserve Determinations
Dark Field Examination
We will be glad to advise with you concerning any laboratory problem
Sterile Containers sent on request
E. T. MANNING, B. S., M. D., Mgr.
&
iiiniiiiiiimiiiiiiiiiiiiMiiiiiiimm’n
IIIIIIHIIIIHIIIIIIIIIIIIIII
iiiiiiiiiniiiiiimiiiiiiiiiiiiiiiiiHinmriiiiiiifiiiiiifiiHiiiniiiiiiii]
□
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Journal of Iowa State Medical Society
XXIX
For Pneumonia
ANTI-PNEUMOCOCCIC SERUM SQUIBB LEUCOCYTE EXTRACT SQUIBB
(Type 1) (From the Horse)
The contract of the State Board of Health makes
Squibb Biologicals the only official serums and
vaccines in Iowa
For the
Venereal Campaign
Solargentum
I'rotargent.um
Prophylaelir. Ointment
Note Special
DIPHTHERIA ANTITOXIN SQUIBB
1.000 Units Packages $0.50
3.000 Units Packages 1.23
6.000 Units Packages 1.80
10,000 Units Packages 3.36
10,000 Units Packages 6.70
SMALLPOX VACCINE SQUIBB
Packages of 10 Capillary Tubes $0.80
Packages of 6 Capillary Tubes 40
Contract Prices
TETANUS ANTITOXIN SQUIBB
1,600 Units Packages $1.67
8.000 Units Packages 2.87
6.000 Units Packages 4.00
TYPHOID VACCINE SQUIBB
1 Immunization Treatment (3 syringes) $0.86
1 Immunization Treatment (3 Ampuls) . . .28
1 30-Ampul Package (Hospital) 3.60
Distributors in Every County
General Distributors
Iowa State Board of Health, Des Moines, Iowa
E. R. Squibb & Sons, 323 West Lake Street, Chicago, 111
E R.- Squibb h. Sons , New York
M A M U F ACT U R I CHEMISTS TO THE MEDICAL PROFESSION SINCE 18 56
When writing to advertisers please mention The Journal of Iowa State Medical Society
XXX
Journal of Iowa State Medical . Society
T
HERE is **Blue Sky** and ^*Water** in merchandise
as well as in stocks and shares. The country is full of merchan-
dise of all kinds which is left ov^er from war time when “any-
thing was acceptable”. ^Vise Buyers will confine their
dealings to:
HOUSES OF REPUTE^thosc they
know have a reputation to sustain.
A Reliable House handles only Reliable Merchandise —
don^t buy from a house you do not know. No matter what
the smooth salesman tells you —
Price Depends on Quality
You cannot get “Something for Nothing”.
The W. G. CLEVELAND COMPANY, inc.
OMAHA and SAINT LOUIS
(A Surgical House since 1891 — thirty years continuous business -with Physicians and Hospitals)
o
o
The Nebreiska Laboratory
354 Brandeis Theatre Bldg.
OMAHA
Wassermann Tests
Autogenous Vaccines
Blood Chemistry
Urine Chemistry
Blood Counts
Tissue Examinations
Bacteriological Examinations
Colloidal Gold Reactions
Alkali Reserve Determinations
Dark Field Examination
We will be glad to advise with you concerning any laboratory problem
Sterile Containers sent on request
E. T. MANNING, B. S., M. D., Mgr.
iiMtimiiMimtMiiiiiiiiimiiiiiiiiimmiiiiMiiiiiiiiiiiMMiHiiiMiimiiii
□
When writing to advertisers please mention The Journal of Iowa State Medical Society
rr
I J >A
tlfte 3fournaI of tfje '
Sotoa ^tate jHeiJital ^otietp
ISSUKU MONTHLY
\'0L. XII, Xo. 7
Des ]\Ioi.nes, Iowa, July 15, 1922
CONTENTS
Single Copies ‘iO Cent>
$2.75 i*er Year
ORIGIN A E ARTICEKS
Tiu* Uilation ot Splenic Syndromes to the rathoU»gy of the
1‘dood. U'i'lliam J. Mayo, M.D., Rochester, M tmiesota
I'he Diagnosis of Foreign Bodies in the Uronclii.
Thomas McCrae, M.D., Rhihdclphia
I'ractures of the Lower End of the Radius.
P. A. Bendixcn, F.A.C.S., l)a:cnf*ort
\ Fractical Discussion of Mental Stamlardization,
Frank A. Ely, M.fK, Des Moines
Surgical Injuries of the Bile Passages
A. E Acher. M.D.,
*rhe She])pard-Towner Bill Kate Har[*el, M.D., Boone
I liysicians Who Located in Iowa in the Period between 1830
an<l IMIO 1). S. Fairchild. MJ)., F.A.C.S., Clinton
EDITORIAL
St. Louis Meeting of the American Medical Association 270
Intracardiac Injection of Adrenalin in Heart Arrest 27'i
Malignant Growths Developing in L’ndescended Testicles... 27;5
MIXL'TKS OF THE IOWA STATE MEDICAL SOCIETY
SE\'EXTY FIRST ANNUAL SESSION 27-1
TRANSACTIONS HOUSE OF DELEGATES IOWA
STATE MEDICAL SOCT ETY— SEVENTY-FIRST
ANNUAL SESSION 27 ti
IOWA STATE MEDICAL SOCI ETY— OFFICERS AND
COMMITTEICS 204
248
252
250
Fort Dodge 2(i2
205
267
(Continued on Next Page)
Next Annual Session May 9, 10. 11, 1923, Ottumwa
ICnlered as second-class matter January 22, 1915, at the post office at Des Moines. Iowa, under the Act of August 24, 1912
.\cceptance for mailing at special rate of postage provided for in Section 1108, Act of Oct. 8, 1917, authorized on July 8. lOlS
Creosote Effeet
free from the disagreeable effects on the stomach may be
obtained by administering CALCREOSE (Calcium creo-
sotate), a mixture containing in loose chemical combina-
tion approximately equal weights of creosote and lime.
H'rite for “The Calcreose Detail Man" and Samples
The Maltbie Chemical Company
NEWARK, NEW JERSEY
^ S'
11
Journal of Iowa State Medical Society
CONTENTS— CONTINUED
society proceedings
Clinton County Metlical Society 298
I'reniont County Medical Society 295
Jackson County Medical Society 20S
I,ec C’ouniy Medical Society 298
Idnn County Me<lical Society 29v5
Mahaska County Medical Society 299
State Society — Iowa Medical Women 299
Hahnemann Medical Society 299
Iowa Clinical Society 300
Important Resolutions Adopted by the Radiological Society
of North America at its Annual Meeting, Chicago. 1920 300
IOWA STATK r.MX'KRSITV NEWS NOTES 272
MKDICAE NEWS NOTES ' 290
>1 ISCKLE ANEOUS
Kentucky I’hysicians Oppose Shorter Medical Courses 2(57
Radiotherapy in Certain Forms of Uterine Fibroma 269
International Society of Medicine 269
Renal Tuberculosis 269
Public Health Conference 272
Hospital Standardization from the N’iewpoint of the Hospital
Trustees 29.>
HOSPITAL NOTES 300
PERSONAL MENTION 301
OBITUARV 301
HOOK REVIEWS 302-30(5
New and Non-Official Remedies 306
WILLIAM SCHEPPEGRELL, A. M., M. D.
President American Hayfever Prevention
Association. Chief of Hayfever Clinic.
Charity Hospital, New Orleans,
I Says:-
T F the patient applies for
^ treatment during an at-
tack of hayfever, the pollen
extracts are usually ineffec-
tive, and a vaccine should be
used, these being injected at
intervals of one or two days .
until the severity of the at- j
tack subsides.”*
'From Dr. William Scheppegrell’s new book on Hay-
fever and Asthma, Lea & Febiger, Publishers
Bacteriological Laboratories of
G. H. SHERMAN, M. D.
DETROIT, MICH.
YOU UNDERTAKE TO CORRECT AND
CARE FOR YOUR PATIENTS’ VISION, THERE
IN KNOWING THAT
WILL ALWAYS BE
YOUR PRESCRIPTIONS
UHLCO QUALITY
COMPANY
ROCKFORD, ILL.
CBcatnut and Main
UHLEMANN OPTICAL
HomeOMiee:
CHICAGO
When writing to advertisers please mention The Journal of Iowa State Medical Society
3f^ournaI of tfje
Hotoa ^tate J$lct)ical ^ctetp
ISSUED MONTHLY
VoL. XII, Xo. 8
Des -\foiXEs, Iowa, August IS, 1922
Single Copies 30 Cents
$2.75 Per Year
CONTENTS
OKHilNAL AKTICLKS
Digitalis; in Cardiac Disease.
Uettry .1. C Jiristidri , M.D., Boston ;i07
The Effect of Occlusion of the Coronary Arteries on the
Heart’s Action and its Kelationship to Angina Pectoris,
Warfield T. Longcope, M.D., Xeie Yorlc :U I
Syphilitic Aortitis. A Cause of Sudden Death,
H. It 'oodzeard, M.D., Mason City 31 ‘J
\ incent’s Angina as Seen in Civil Practice.
J. E. Rock, M.D., Davenport 3*23
The Hospital and Laboratory as an Aid in Diagnosis and
Treatment of Diabetics. .. .H. L, Rohlf, M.D., Waterloo 329
Mental Measurement in Relation to Medicine,
Reuel H. Sylvester^ Ph.D., Des Moines 330
The Causes of Failure of Operations for Chronic Appendi- President's Address — Medical Society Missouri Valley,
citis Charles J. Roi*.an, M.D., loiea City 322 Charles Ryan, M.D., F.A.C.S., Des ^loines 332
(Continued on Next Page)
Next Annual Session !>Iay 9, lO. 11, 1933, Ottuiikwa
ITitercd as second-class matter January 22, 1915, at the post office at Des Moines, Iowa, under the Act of August 24, 1912
.Acceptance for mailing at special rate of postage provided for in Section 1103, Act of Oct. 3, 1917, authorized on July 8, 1918
Creosote Effeet
free from the disagreeable effects on the stomach may be
obtained b\' administering CALCREOSE (Calcium creo-
sotatej, a mixture containing in loose chemical combina-
tion approximately equal weights of creosote and lime.
IFrite for “The Calcreose Detail Man” and Samples
The Maltbie Chemical Company
NEWARK, NEW JERSEY
100
Grain,
11
Journal of Iowa State Medical Society
CONTENTS-CONTINUED
KDITOKIAL
The Economic Position of Hernia
Xeurops>'chiatric Problems with Disabled X’eterans
Providing for an Increase in the Number of Rural Doctors.. 3^.3
Division of Fees ooii
Fowler’s Solution
Malpractice Cases in New Vork
Radium in Congo i>44
SOCIETY KROCEEDINGS
Dubu(4ue County Medical Society 34.')
(Jreene County Medical Society 34.'>
Marion County Medical Society 34.")
Page County Medical Society 3 1(5
Van Huren County Medical Society 34<>
W all Lake District Medical Society 34r>
Medical Women's International Association 34 7
Thirty-fifth Annual Meeting Medical Society Missouri Valley 340
IOWA STATE UXIVERSITV NEWS NOTES 34:>
PERSONAL MENTION 347
HOSPITAL NOTES 34S
OBITUARY 34S
MISCELLANEOUS
Report of the Special Committee on Traumatic and Industrial
Hernia 330
Report of Recommendations of the American Railway Asso-
ciation in Connection with Hospital Standardization.... 341
The Schick Reaction 343
ROOK REVIEWS 349-3.50
WILLIAM SCHEPPEGRELL, A. M., M. D.
President American Hayfever Prevention
Association. Chief of Hayfever Clinic,
Charity Hospital, New Orleans,
Says: —
*TF the patient applies for
^ treatment during an at-
tack of hayfever, the pollen
extracts are usually ineffec-
tive, and a vaccine should be
used, these being injected at
intervals of one or two days
until the severity of the at-
tack subsides.”*
’From Dr. William Scheppegrcll’s new book on Hay-
fever and Asthma, Lea & Febiger, Publishers
Bacteriological Laboratories of
G. H. SHERMAN, M. D.
DETROIT, MICH.
State University of Iowa Maternity
IOWA CITY, IOWA
The Department of Obstetrics of the University of Iowa offers the fol-
1 lowing advantages to clinical cases referred for treatment.
1. A COMPLETELY EQUIPPED DE-
PARTMENT with specially trained medi-
cal and nursing staff in constant attend-
ance on cases.
' 2. FIFTY BEDS including separate quarters
j; for legitimate, illegitimate, and venereal
pregnant women.
f 3. SEPARATE DELIVERY ROOM and iso-
lation nursery are provided for venereal
' cases and they are treated before and after
‘ delivery.
4. LEGITIMATELY PREGNANT CASES
can stay at the hospital two weeks prior to
delivery, or longer if complications warrant
it.
' .r CASES COMPLICATED by other medical
or surgical conditions whether legitimately
Address all inquiries for further information to Dr. Frederick H, Falls,
Head of the Department, University Hospital, Iowa City, Iowa.
or illegitimately pregnant may be entered
at any time. This includes such cases as
Nephritis, pernicious vomiting, eclamptic
or preeclamptic toxemia, cardiac disease,
chorea, anemias, or cases running a high
blood pressure or a persistent albuminuria.
6. ILLEGITIMATELY PREGNANT WO-
MEN will be received as early as the
seventh month, or earlier if any complica-
tion e.xists.
7. ARRANGEMENTS FOR ADOPTION
can he made through the social service.
In addition cases may be sent in for clin-
ical examination and diagnosis either as an
out patient or as a liouse case for a period
of observation and a report returned to the
doctor referring the case.
When writing to advertisers please mention The Journal of Iowa State Medical Society
Wit Jfouraal of tlje
^otua ^tate J^lebical ^octetp
ISSUED MONTHLY
VoL. XII, No. 9
Des Moines, Iowa, September 15, 1922
Single Copies 30 Cent*
$2.75 Per Year
CONTENTS
ORIGINAL ARTICLES
Our Present Knowledge and Experience Concerning Caesar-
ean Section Edxvard P. Davis, M.D., Philadelphia 351
The Human Breast, a Plea for Well Directed Treatment
Based on More Accurate Diagnosis, William Seaman
Bainbridgc, Commander il/.C*., U.S.N.R.F., Xezv York City 354
Suprapubic Prostatectomy; Technic and After Results,
George E. Decker, M.D., Davenport 360
Ectopic Gestation as a Vital Subject to the Patient and to
the Practitioner. .Cora/ R. Armentrout, M.D., Keokuk 362
(Continued o
Next Annual Session May
Observations by a Woman Physician in State Hospital for
Insane Pauline Leader, M.D., Clarinda 366
.Vasal Headaches Otis R. H'olfe, M.D., and
F. L. Wa/irer, .\f.D., .Marshalltown 370
Hyper and Hypo-Thyroidism.
John W. Shuman, M.D., F.A.C.S., Sioux City 374
Physicians Who Located in Iowa in the Period Between 1850*
1860 D. S. Fairchild, MJ)., F.A.C.S., Clinton 375
1 Next Page)
9. 10. 11, 1923, Ottumwa
Entered as second-class matter January 22, 1915, at the post office at Des Moines, Iowa, under the Act of August 24, 1912
.\cceptance for mailing at special rate of postage provided for in Section 1103, Act of Oct. 3, 1917, authorized on July 8, 1918
IN PULMONARY TUBERCULOSIS
CREOSOTE EFFECT MAY BE OBTAINED
WITHOUT UNTOWARD SYMPTOMS on
the gastro-intestinal tract; no nausea, vomiting,
gastric distress or irritability by using
CALCREOSE (Calcium creosotate), a mixture containing in
loose chemical combination, approximately equal weights of creo-
sote and lime. Patients do not object to taking CAI.CREOSE,
even in large doses for long periods of time.
Write for “The Calcrcose Detail Man”
The Maltbie Chemical Company
NEWARK, NEW JERSEY
Journal of Iowa State Medical Society
ii
CONTENTS— CONTINUED
editorial
Perkin’s Tractors
Medical Care for Disabled X’eterans 379
Personal — Dr. James Taggart Priestley 380
Chiropractors 381
Homeopathy in State L’niversities 381
SOCIETY PROCEEDINGS
Tri-State Medical Association 38:1
Clinic Polk County Medical Society 385
Mississippi Valley Medical Association 38,7
.MEDICAL NEWS .VOTES ., 384
PERSONAL .MENTION 385
HOSPITAL NOTES 3S(i
M.-VRELVCES 380
OBITUARY 380
MISCELLANEOUS
.Action for Services Rendered Non-Resident Patient 377
Treatment of .\ngioma by Radium 377
Protest .Against the Proposed Tooth Brush Tariff 385
President Lowell on High Cost of Medical Education 385
BOOK REVIEWS .Adv page xvi
WILLIAM SCHEPPEGRELL, A. M., M. D.
President American Hayfever Prevention ^
Association. Chief of Hayfever Clinic.
Charity Hospital, New Orleans,
Says: —
“TF the patient applies for
^ treatment during an at-
tack of hayfever, the pollen
extracts are usually ineffec-
tive, and a vaccine should be
used, these being injected at
intervals of one or two days
until the severity of the at-
tack subsides.”*
‘From Dr. William Scheppegrell’s new book on Hay-
fever and Asthma, Lea & Febiger, Publishers
Bacteriological Laboratories of
G. H. SHERMAN, M. D.
DETROIT. MICH.
In addition to the usual courses
The Faculty of
Loyola Post-Graduate School of Medicine
NEW ORLEANS, LA.
offers
THREE INTENSIVE SIX WEEKS’ COURSES
Running concurrently October 15th to December 1st
A Course in Medicine — A Course in Surgery
A Course in the Eye, Ear, Nose and Throat
These courses are offered to the Profession without charge, except for a registration fee
of $10.00. Classes will be limited to one hundred in each course. Write for reservation, in-
dicating which course is desired.
Loyola Post-Graduate School of Medicine
New Orleans, La.
Enclosed please find my check for $10. 00 to cover
registration in the course in
Surgery Medicine Eye, Ear, Nose and Throat
given by your School, October 15th to December 1st.
For literature, information about this and
other courses, address
JOSEPH A. DAHNA, M. D„ Secretary
1533 Tulane Avenue
NEW ORLEANS, LA.
Name
Address
When writing to advertisers please mention The Journal of Iowa State Medical Society
tlfje Jfournal of tlje
3(otoa ^tatc J^cbital ^wtictp
ISSUED MONTHLY
VoL. XII, No. 10
Des Moines, Iowa, October 15, 1922
Single Copies 30 Cents
$2.75 Per Year
CONTENTS
ORIGINAL ARTICLES
The Pros and Cons of Foreign Protein Injections in Af-
fections of the Eye,
James M. Patton, M.D., F.A.C.S., Omaha 387
The Occult Diseases of Childhood,
J. Claxton Gittings, M.D., Philadelphia 391
Psychiatric Analysis of the Children in the State Juvenile
Home, Lawson G, Lowrey, M.D.,
John J. B. Morgan, Ph.D., Iowa City 396
The Treatment of Fractures,
O. C. Morrison, M.D., Carroll 404
(Continued i
A Brief History of Public Health Movement,
Lena A. Beach, M.D., Rockwell City 407
Renal Functional Tests in Chronic Nephritis,
F. H, Lamb, M.D., Davenport 410
EDITORIAL
The Embargo on German Dyes and Synthetic Drugs and
Chemicals 415
Benjamin Franklin as a Medical Contributor 416
Brachial Birth Paralysis 417
Evil Effects of Tobacco 417
Next Page)
Next Annual Session Mar 9, 10, 11, 1923, Ottnniwa
Entered as second-class matter January 22, 1915, at the post office at Des Moines, Iowa, under the Act of August 24, 1912
Acceptance for mailing at special rate of postage provided for in Section 1103, Act of Oct. 3, 1917, authorized on July 8, 1918
IN PULMONARY TUBERCULOSIS
CREOSOTE EFFECT MAY BE OBTAINED
WITHOUT UNTOWARD SYMPTOMS on
the gastro-intestinal tract; no nausea, vomiting,
gastric distress or irritability by using
CALCREOSE (Calcium creosotate j is a mixture containing in
loose chemical combination, approximately equal weights of creo-
sote and lime. Patients do not object to taking CALCREOSE,
even in large doses for long periods of time.
Write for “The Calcreose Detail Man”
The Maltbie Chemical Company
NEWARK, NEW JERSEY
Remember the Des Moines Clinic — October 18, 19, 20
11
Journal of Iowa State Medical Society
CONTENTS— CONTINUED
EDITORIAL — Continued
Consultation on Venereal Disease by Correspondence 418
Radium Insurance 419
Des Moines as a Medical Center 419
SOCIETY FKOCKBDINGS
Greene County Medical Society 420
Jones County Medical Society 420
Van Buren County Medical Society 420
Austin Flint-Cedar Valley Medical Association 420
Medical Society of Cedar Falls 421
IOWA STATE UNIVERSITY NEWS NOTES 418
hospital notes 421
PERSONAL mention 421
MARRIAGES 422
OBITUARY 423
MISCELLANEOUS
Trauma as a Factor in the Etiology of Hydronephrosis 414
Report of the Committee on Arrangements, Des Moines
Session 423
New and Non-Official Remedies Adv. p. xvi
BOOK REVIEWS 424-426
WILLIAM SCHEPPEGRELL, A. M., M. D.
President American Hayfeyer Prevention
Association. Chief of Hayfever Clinic,
Charity Hospital, New Orleans,
Says; —
‘TF the patient applies for
^ treatment during an at-
tack of hayfever, the pollen
extracts are usually ineffec-
tive, and a vaccine should be
used, these being injected at
intervals of one or two days
until the severity of the at-
tack subsides.”*
*From Dr. William Scheppegrell’s new book on Hay-
fever and Asthma, Lea & Febiger, Publishers
Bacteriological Laboratories of
G. H. SHERMAN, M. D.
DETROIT, MICH.
Radium Rental Service
Radium loaned to physicians at moderate rental fees,
or patients may be referred to us for treatment if pre-
ferred.
Careful consideration will be given inquiries concern-
ing cases in which the use of Radium is indicated.
BOARD OF DIRECTORS
William L. Baum. M. D. N. Sproat Heaney, M. D. Frederick Menge, M. D.
Louis E. Schmidt, M. D. Thomas J. Watkins, M. D.
The Physicians Radium Association
1102 Tower Building, 6 N. Michigan Ave.
Telephones: Randolph 6897-6898 CHICAGO, ILL. William L. Brown, Manager
When writing to advertisers please mention The Journal of Iowa State Medical Society
r
Jfoumal of t!)e
Hotoa ^tate jHefiical ^ocietp
ISSUED MONTHLY
VoL. XII, No. 11 Des Moines, Iowa, November 15, 1922
Single Copies 30 Cents
$2.75 Per Year
CONTENTS
ORIGINAL ARTICLES
Medical Ideals Evan S. Evans, M.D., Grinnell 427
Acute Perichondritis of the Larynx, with Report of Case,
Frank A. Will, M.D., Des Moines 430
The Thoracoscopy and its Practical Importance, Especially
in the Surgery of the Chest,
H. C. Jacobaeus, M.D., Stockholm, Siveden 432
Chronic Appendicitis,
George Kessel, M.D., F.A.C.S., Cresco 437
The Diagnosis of Appendicitis,
M. J. Kenefick , M.D., Algona 440
The Radiation Treatment of Hyperthyroidism and the Basal
Metabolism Test,
Harold Swanberg, M.D., Quincy, Illinois 412
(Continued i
Ophthalmology and the Lesser Alcohols,
James M. Downing, M.D., Des Moines 446
Indications for Urological Examination,
Raymond L. Latchem, M.D., Sioux City 449
Adenoids and Eye Strain in School Children — Why Many
Leave School Percy R. Wood, M.D., Waterloo 451
Testimonial Dinner for Dr. James Taggart Priestley 432
Physicians Active in Public Health Work 457
Report of the Bureau of Venereal Disease Control, Wilbur
S. Conkling, M.D 458
Next Page)
Next Annual Session May 9. 10, 11, 1923, Ottumwa
Entered as second-class matter January 22, 1915, at the post office at Des Moines, Iowa, under the Act of August 24, 1918
Acceptance for mailing at special rate of postage provided for in Section 1103, Act of Oct. 3, 1917, authorized on July 8, 1918
IN PULMONARY TUBERCULOSIS
CREOSOTE EFFECT MAY BE OBTAINED
WITHOUT UNTOWARD SYMPTOMS on
the gastro-intestinal tract; no nausea, vomiting,
gastric distress or irritability by using
CALCREOSE (Calcium creosotate) is a mixture containing in
loose chemical combination, approximately equal weights of creo-
sote and lime. Patients do not object to taking C.ALCREOSE,
even in large doses for long periods of time.
Write for “The Color ease Detail Man”
The Maltbie Chemical Company
NEWARK, NEW JERSEY
11
Journal of Iowa State Medical Society
CONTENTS-CONTINUED
EDITORIAL
Views of the Lay Press on Dr. de Schweinitz, Address of
Acceptance as President-Elect A. M. A., St. Louis 4fil
Proposed Tariff on Microscopes and Scientific Apparatus... 4il]
SOCIETY PROCEEDINGS
.Vppanoose County Medical Society 40.1
Buena Vista and Plymouth County Medical Societies 403
Greene County Medical Society 403
Johnson County Medical Society 404
Jones County Medical Society 404
Pocahontas County Medical Society 404
Tama County Medical Society 404
Van Buren County Medical Society 404
Upper Des Moines Medical Association 404
Iowa Surgical Society 404
American Surgical Association 404
IOWA STATE UNIVERSITY NEWS NOTES 402
MEDICAL NEWS NOTES 403
HOSPITAL NOTES 404
PERSONAL MENTION 405
OBITUARY 460
■MARRIAGES 467
MISCELLANEOUS
State Medical Library 452
Sheppard-Towner Act — Iowa 460
Workmen’s Compensation Law in New York .Amended 40‘J
Standardizing of Hospitals L'rged 405
New and Non-Official Remedies 407
CONSTITUTION ■AND BY-L^AWS— lOW^A ST^ATE MED-
ICAL SOCIETY 468
BOOK REVIEWS 47G
Acute Respiratory
Diseases offer an ex-
cellent opportunity
to demonstrate the
value of Therapeutic
Immunization with
Bacterial Vaccines ;
DATA FURNISHED ON REQUEST
Bacteriological Laboratories of
G. H. SHERMAN. M. D.
DETROIT. MICH.
rnz:
— ; — 1 —
1
The Laboratory of Surgical Technique |
1
f ■
1
OF CHICAGO I
I
Near Augustana Hospital |
1
The regular course covers two vceeks, and combines 1
i
Clinical Teaching tvith the Practical Work that has f
I
been given at the Laboratory for the past eight years. j
1
In addition to thorough instruction in Surgical Tech- |
1
nique, the Surgical ■A.natomy of the following structures |
and regions is covered: Large and Small Intestines and i
i
■Appendix; Stomach. Gall Bladder and Ducts; Kidnev 1
1
and L'reter; Female Pelvic Organs; Inguinal and Fe- i
1
moral Regions; Breast and Axilla; Thyroid Gland and 1
I
■Anterior Cervical Triangle; and the surgical anatomy 1
I
that is given in connection with the demonstrations of 1
1
Xerve and Tendon Sutures, Bone Work, Amputations, 1
1
Pott's Fracture, etc. I
1
■Arrangements can be made for an intensive period of i
1
one week. i
1
Special instruction can be had in one or more oper- |
1
ations. i
1
PERSOX^AL IXSTRUCTIOX I
j
■ACTUAL PR.ACTICE |
1
H ' iH ■
EXCEPTIOXAL EQUIPMEXT |
1
For Information Address |
DR. EMMET A. PRINTY, Director, 2040 Lincoln Ave. |
(Formerly 7629 Jeffery Avenue) |
i_j-
CH
When writing to advertisers please mention The Journal of Iowa State Medical Society
JToumal of
Sotoa ^tate jfHciiual ^ttefp
ISSUED MONTHLY
VoL. XII, No. I4-] Des Moines, Io\v.\, December 15, 1Q22
CONTENTS
ORIGINAL ARTICLES
Oration on Medicine B. L. Biker. M.D., Leou 47^t
Injuries lo the Spine not Involving the Cord,
Oliver J. Fay. M.D., F.A.C.S., Des Moines 431
Vertebral Fractures with Cord Involvement,
John Walter Martin, yf.D., Des Moines 4S4
Tumors of the llreast from the Standpoint of the General
Practitioner and the ('leneral Surgeon.
.-//7/iHr Dean Sevan. M.D., ChUago 480
(Continued i
pHigram of the American College of Surgeons,
Franklin Martin. M.D., F.A.C.S., Chicago 400
Kthics in Fractures F. A. Hennessey^ M.D., Cahnar 498
Mistakes in the Treatment of Fractures,
Howard L. Beye. M.D., UKca City 500
The I.alxiratory Practice of Medicine,
H. B. Robertson. M.D., Rochester, Minnesota 5(i:l
Next Page)
Next Annual Session May 9, 10. 11, 1923, Ottumwa
Entered as second-class matter January 22, 1915, at the post office at Des Moines, Iowa, under the Act of August 24, 1912
Acceptance for mailing at special rate of postage provided for in Section 1103, Act of Oct. 3, 1917, authorized on July 8, 1918
IN PULMONARY TUBERCULOSIS
CREOSOTE EFFECT MAY BE OBTAINED
WITHOUT UNTOWARD SYMPTOMS on
the gastro-intestinal tract; no nausea, vomiting,
gastric distress or irritability by using
CALCREOSE (Calcium creosotate) is a mixture containing in
loose chemical combination, approximately equal weights of creo-
sote and lime. Patients do not object to taking C.^LCREOSE,
even in large doses for long periods of time.
Write for “The Calcreose Detail Man”
The Maltbie Chemical Company
NEWARK, NEW JERSEY
11
Journal of Iowa State Medical Society
CONTENTS— CONTINUED
EDITOKIAL
The Question of Representation of the Sections in the
House of Delegates of the American Medical, Association 507
Dr. George H. Simmons 507
Ethics of Fracture Cases 508
Official Bulletin of the American College of Surgeons 508
Foreigners as Assistants in Italian Clinics 509
The American Medical Association of Vienna 509
SOCIETY PROCEEDINGS
Hardin County Medical Society 509
Iowa County Medical Society 509
Jasper and Marian County Medical Societies 510
Jones County Medical Society 510
Mills County Medical Society 509
Pocahontas County Medical Society 510
Polk County Medical Society 510
Scott County Medical Society 510
Wayne County Medical Society 510
Woodbury County Medical Society 511
Rotna N'alley Medical Society 511
Iowa X-Ray Club *511
American Urological Association 511
PERSONAL MENTION 512
HOSPITAL NEWS 513
MARRIAGES 516
OBITUARY 511
MISCELLANEOUS
Infectious Jaundice 506
Important Announcement 506
The Annual Collection 50C
National Board of Medical Examiners 506
Dr. Henry G. Langworthy 511
Orphans Need Help 513
New Home Hynson W'estcott & Dunning 516
Acute Respiratory
Diseases offer an ex-
cellent opportunity
to demonstrate the
value of Therapeutic
Immunization with
Bacterial Vaccines
DATA FURNISHED ON REQUEST
Bacteriological Laboratories of
G. H. SHERMAN. M. D.
DETROIT. MICH.
In addition to the usual courses
The Faculty of
Loyola Post-Graduate School of Medicine
NEW ORLEANS, LA.
offers
THREE INTENSIVE SIX WEEKS’ COURSES
Running concurrently February 1st to March 15th
A Course in Medicine — A Course in Surgery
A Course in the Eye, Ear, Nose and Throat
These courses are offered to the Profession without charge, except for a registration fee
of $10.00. Classes will be limited to one hundred in each course. Write for reservation,
indicating which course is desired.
Loyola Post-Graduate School of Medicine
New Orleans, La.
Enclosed please find my check for $10.00 to cover
registration in the course in^
Surgery Medicine Eye, Ear, Nose and Throat
given by your School, February 1 to March 15.
For literature, information about this and
other courses, address
JOSEPH A. DANNA, M. D., Secretary
1533 Tulane Avenue
NEW ORLEANS, LA.
Name
Address
When writing to advertisers please mention The Journal of Iowa State Medical Society
Journal of Iowa State Medical Society
xxvii
“To enable, by a simple vaccination,
to pick out those who are naturally im-
mune to diphtheria from those who are
susceptible, is surely a diagnostic
achievement. It is just so much
greater because the test is harmless
and prevents the unnecessary waste of
expensive antitoxin, atid it saves large
numbers of children the inconvenience
and annoyance of the injection itself.
“Far better to vaccinate against a
possible infection than take a chance;
and, better still, to know with a rea-
sonable degree of assurance that such
a vaccination is not necessary. Not to
take precautions is to stand on a foot-
ing with the anti-vaccinationists.” —
Louisiana State Health Board Bulletin.
Eradicate diphtheria
by immunization
SCHICK TEST SQUIBB is a reliable diagnostic
test for susceptibility to diphtheria. A safe guide in
determining the need of Toxin- Antitoxin immunization.
DIPHTHERIA TOXIN -ANTITOXIN MIX-
TURE SQUIBB establishes an active immunity
against diphtheria, lasting three years or longer. As
easy to administer as typhoid vaccine,
DIPHTHERIA ANTITOXIN SQUIBB is isoton-
ic with the blood. Small bulk, with a minimum of
solids, insures rapid absorption and lessens the dangers
of severe anaphylactic reaction.
Complete information on request
MANUFACTURING CHEMISTS TO THE MEDICAL PROFESSION SINCE 1858.
When writing to advertisers please mention The Journal of Iowa State Medical Society
xxviii
Journal of Iowa Sta* , .oal Society
The season is approaching when YOU will be called upon for many tonsillectomies. Are you
equipped to perform these by the most up-to-date, scientific and safe methods?
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The Nebraska Laboratory
of
Clinical Pathology
354 Brandeis Theatre Building, Omaha, Nebraska
DR. H. E. EGGERS DR. E. T. MANNING
Consultant in Manager
Pathology
DR. J. T. MYERS
Consultant in
Bacteriology and
Chemistry
o
When writing to advertisers please mention The Tournal of Iowa State Medical Society
Journal of Iowa State Medical Society
XX VI I
“To enable, by a simple vaccination,
to pick out those who are naturally im-
mune to diphtheria from those who are
susceptible, is surely a diagnostic
achievement. It is just so much
greater because the test is harmless
and prevents the unnecessary waste of
expensive antitoxin, and it saves large
numbers of children the inconvenience
and annoyance of the injection itself.
“Far better to vaccinate against a
possible infection than take a chance;
and, better still, to know with a rea-
sonable degree of assurance that such
a vaccination is not necessary. Not to
take precautions is to stand on a foot-
ing with the anti-vac cinationists.” —
Louisiana State Health Board Bulletin.
Eradicate diphtheria
by immunization
SCHICK TEST SQUIBB is a reliable diagnostic
test for susceptibility to diphtheria. A safe guide in
determining the need of Toxin- Antitoxin immunization.
DIPHTHERIA TOXIN -ANTITOXIN MIX-
TURE SQUIBB establishes an active immunity
against diphtheria, lasting three years or longer. As
easy to administer as typhoid vaccine.
DIPHTHERIA ANTITOXIN SQUIBB is isoton-
ic with the blood. Small bulk, with a minimum of
solids, insures rapid absorption and lessens the dangers
of severe anaphylactic reaction.
Complete information on request
E-R;S(ipiBB tSoHS, New York
MANUFACTURING CHEMISTS TO THE MEDICAL PROFESSION SINCE 1858.
When writing to advertisers please mention The Journal of Iowa State Medical Society
XXVlll
Journal of Iowa State Medical Society
NEARLY THREE MILLION DOLLARS
Do You Realize How Much That Is?
If you had to count three millions at the rate of one hundred per minute (working
Union hours — 8 hours a day — days a week) you would have steady work for
over ELEVEN WEEKS.
iust counting — counting — counting — no time off for anything.
THREE MILLION DOLLARS is just about the amount of OUR BUSINESS dur-
ing the last eleven years with the MEDICAL PROFESSION.
There must be a REASON — There IS a reason — in fact there are TWO REASONS
for this large volume.
Quality and Satisfaction
OMAHA
SURGICAL SUPPLIES
ST. LOUIS
a
The Nebraska Laboratory
354- Brandeis Theatre Bldg.
OMAHA
Wassermann Tests
Autogenous Vaccines
Blood Chemistry
Urine Chemistry
Blood Counts
Tissue Examinations
Bacteriological Examinations
Colloidal Gold Reactions
Alkali Reserve Deterrrdnanons
Dark Field Examination
We will be glad to advise with you concerning any laboratory problem
Sterile Containers sent on request
E. T. MANNING, B. S., M. D., Mgr.
iiiiiiiiiiiniiiiiiiimiii
iiimniMiiiniiiiiiil
□
When writing to advertisers please mention The Journal of Iowa State Medical Society
Journal of Iowa State Medical Society
XXVll
“To enable, by a simple vaccination,
to pick out those who are naturally im-
mune to diphtheria from those who are
susceptible, is surely a diagnostic
achievement. It is just so much
greater because the test is harmless
and prevents the unnecessary waste of
expensive antitoxin, and it saves large
numbers of children the inconvenience
and annoyance of the injection itself.
“For better to vaccinate against a
possible infection than take a chance;
and, better still, to know with a rea-
sonable degree of assurance that such
a vaccination is not necessary. Not to
take precautions is to stand on a foot-
ing with the anti-vaccinationists.” —
Louisiana State Health Board Bulletin.
Eradicate diphtheria
hy immunization
SCHICK TEST SQUIBB is a reliable diagnostic
test for susceptibility to diphtheria. A safe guide in
determining the need of Toxin-Antitoxin immunization.
DIPHTHERIA TOXIN -ANTITOXIN MIX-
TURE SQUIBB establishes an active immunity
against diphtheria, lasting three years or longer. As
easy to administer as typhoid vaccine.
DIPHTHERIA ANTITOXIN SQUIBB is isoton-
ic with the blood. Small bulk, with a minimum of
solids, insures rapid absorption and lessens the dangers
of severe anaphylactic reaction.
Complete information on request
Mi
MANUFACYURING chemists 'to the medical profession since 1858.
When writing to advertisers please mention The Journal of Iowa State Medical Society
XXVlll
Journal of Iowa State Medical Society
NEARLY THREE MILLION DOLLARS
Do You Realize How Much That Is?
If you had to count three millions at the rate of one hundred per minute (working
Union hours — 8 hours a day — days a week) you would have steady work for
over ELEVEN WEEKS.
just counting — counting — counting — no time off for anything.
THREE IMILLION DOLLARS is just about the amount of OUR BUSINESS dur-
ing the last eleven years with the MEDICAL PROFESSION.
There must be a REASON — There IS a reason — in fact there are TWO REASONS
for this large volume.
Qimlity and Satisfaction
OMAHA
SURGICAL SUPPLIES
ST. LOUIS
(3
Q
The Nebreiska Laboratory
354- Brandeis Theatre Bldg.
OMAHA
Wassermann Tests
Autogenous Vaccines
Blood Chemistry
Urine Chemistry
Blood Counts
Tissue Examinations
Bacteriological Examinations
Colloidal Gold Reactions
Alkali Reserve Determinations
Dark Field Examination
We will be glad to advise with you concerning any laboratory problem
Sterile Containers sent on request
E. T. MANNING, B. S., M. D., Mgr.
o
When writing to advertisers please mention The Journal of Iowa State Medical Society
louKNAL OF Iowa State Medical Society
xxvii
The development of the
Schick Test and of Diph-
theria Toxin-Antitoxin nas
made possible the eradica-
tion of diphtheria as an
epidemic disease.
Immunize now-
before Sehool opens
SCHICK TEST SQUIBB is a reliable diagnostic test for
susceptibility to diphtheria. A safe guide in determin-
ing the need of Toxin-Antitoxin immunization.
DIPHTHERIA TOXIN-ANTITOXIN MIXTURE
SQUIBB establishes an active immunity against diph-
theria, lasting three years or longer. As easy to ad-
minister as typhoid vaccine.
DIPHTHERIA ANTITOXIN SQUIBB is isotonic with
the blood. Small bulk, with a minimum of solids, in-
sures rapid absorption and lessens the dangers of
severe anaphylactic reaction.
Complete information on request.
E R: Squibb &.Sons
MANUTACnnUNC CHEMISTS TO THE MEDICAL PSOFESSION SINCE 1858
When writing to advertisers please mention The Journal of Iowa State Medical Society
XXVU)
Journal of Iowa State Medical Society
NEARLY THREE MILLION DOLLARS
Do You Realize How Much That Is?
If you had to count three millions at the rate of one hundred per minute (working
Union hours- — 8 hours a day — days a week) you would have steady work for
over ELEVEN WEEKS.
just counting — counting — counting — no time off for anything.
THREE MILLION DOLLARS is just about the amount of OUR BUSINESS dur-
ing the last eleven years with the MEDICAL PROFESSION.
There must be a REASON — There IS a reason — in fact there are TWO REASONS
for this large volume.
Quality and Satisfaction
OMAHA
SURGICAL SUPPLIES
ST. LOUIS
□h
iiiiimiiiitiiiiiiMiiini
□
The Nebraiska Laboratory
354 Brandeis Theatre Bldg.
OMAHA
Wassermann Tests
Autogenous Vaccines
Blood Chemistry
Urine Chemistry
Blood Counts
Tissue Examinations
Bacteriological Examinations
Colloidal Gold Reactions
Alkali Reserve Determinations
Dark Field Examination
We will be glad to advise with you concerning any laboratory problem
Sterile Containers sent on request
E. T. MANNING, B. S., M. D., Mgr.
When writing to advertisers please mention The Journal of Iowa State Medical Society
Journal of Iowa State Medical Society
xxiii
The development of the
Schick Test and of Diph-
theria Toxin-Antitoxin uas
made possible the eradica-
tion of diphtheria as an
epidemic disease.
Immunize now-
before Sehool opens
SCHICK TEST SQUIBB is a reliable diagnostic test for
susceptibility to diphtheria. A safe guide in determin-
ing the need of Toxin-Antitoxin immunization.
DIPHTHERIA TOXIN-ANTITOXIN MIXTURE
SQUIBB establishes an active immunity against diph-
theria, lasting three years or longer. As easy to ad-
minister as typhoid vaccine.
DIPHTHERIA ANTITOXIN SQUIBB is isotonic with
the blood. Small bulk, with a minimum of solids, in-
sures rapid absorption and lessens the dangers of
severe anaphylactic reaction.
Complete information on request.
E R: Squibb 5i.Sons
MANUTACnmJNC CHtMISTS TO THE MEDICAL PROFESSION SINCE 1858
When writing to advertisers please mention The Journal of Iowa State Medical Society
•xxiv
Journal of Iowa State Medical Society
NEARLY THREE MILLION DOLLARS
Do You Realize How Much That Is?
If you had to count three mihidns at the rate of one hundred per minute (working
Union hours — 8 hours a day— 5j4 days a week) you would have steady work for
over ELEVEN WEEKS.
just counting — counting — counting — no time off for anything.
THREE MILLION DOLLARS is just about the amount of OUR BUSINESS dur-
ing the last eleven years with the AIEDICAL PROFESSION.
There must be a REx\SON — There IS a reason — in fact there are TWO REASONS
for this large volume.
Quality and Satisfaction
OMAHA
SURGICAL SUPPLIES
ST. LOUIS
□ee
O
iiiiiiiiiiitnmiiiiiimiiiiiiimniiiiiiiiiitiiiiimimiiiiimiiiiiiniuuiniuiMimiinniniiiiiiiiMniiniiniiniiiiininiiiniiiiiii
The Nebraska Laboratory
354- Brandeis Theatre Bldg.
OMAHA
Wassermann Tests
Autogenous Vaccines
Blood Chemistry
Urine Chemistry
Blood Counts
Tissue Examinations
Bacteriological Examinations
Colloidal Gold Reactions
xVlkali Reserve Determinations
Dark Field Examination
We will be glad to advise with you concerning any laboratory problem
Sterile Containers sent on request
E. T. MANNING, B. S., M. D., Mgr.
D
liiiiiiiiiimniniiHiHt
iimiiiiiiiiHHiiiimiiiiiiiiiiiiiiiiiMiiiiiiiitiiii
o
When writing to advertisers please mention The Journal of Iowa State Medical Society
Journal of Iowa State Medical Society
xxiii
Group Allergens
Squibb
The importance of testing patients with a large
number of different proteins has emphasized the need
for combining into a series of group allergens, a num-
ber of the closely allied individual ones.
In cooperation with Dr. W. W. Duke, a series
of 27 such groups have been developed for diagnos-
tic purposes, each mixture, with but few exceptions,
containing five allergens, and the endeavor has been
to group them on the basis of actual clinical obser-
vation.
These group mixtures materially lessen the number of tests required and makes
it possible to test each patient with a larger number of proteins with less inconvenience
and in shorter time than would otherwise be involved.
The following groups are now available;
Vegetables (5) Fruits (3)
Meats (2) Fowl
Condiments Beverages
Feathers Pollens (2)
Nuts (2)
Fish (2)
Egg and Milk
Bacterial (3)
Cereals
Mollusks (2)
Hair and
Dander (2)
Thyroxin
Prepared Under License of the
University of Minnesota.
Pure Crystalline Thyroxin is the physiolog-
ically active constituent of the thyroid gland; a
compound of definite end known chemical com-
position containing 65 °f iodine, organically
combined as an integial part of the molecule.
Fifteen grains of desiccated thyroid pre-
pared under favorable conditions contains iip-
proximately 1 64 grain of Thyroxin.
Thyroxin is marketed in two forms — Tablets containing the partially purified
sodium salt for oral administration, and the Pure Crystalline Thyioxin for intravenous
administration in cases where the product is not absorbed quantitatively when given by
mouth.
Complete information on request
E R: Squibb ^Sons
MANUIACTORING CHEMISTS TO THE MEDICAL PROFESSION SINCE 1858
When writing to advertisers please mention The Journal of Iowa State Medical Society
XXIV
Journal of Iowa State Medical Society
NEARLY THREE MILLION DOLLARS
Do You Realize How Much That Is?
If you had to count three millions at the rate of one hundred per minute (, working
Union hours — 8 hours a day — days a week) you would have steady work for
over ILLEVEN \\ EEKS.
just counting — counting — counting — no time off for anything.
THREE MILLION DOLLARS is just about the amount of OUR RL.SINJLSS dur-
ing the last eleven years with the iMEDICAL PROEESSK)X.
There must he a REASON — There IS a reason — in fact there are 'I'WO RlfASONS
for this large volume.
Quality and Satisfaction
OMAHA
SURGICAL SUPPLIES
ST. LOUIS
D
a
The Nebraska Laboratory
3S4 Brandeis Theatre Bldg.
OMAHA
Wassermann Tests
Autogenous Vaccines
Blood Chemistry
Urine Chemistry
Blood Counts
Tissue Examinations
Bacteriological Examinations
Colloidal Gold Reactions
Alkali Reserve Determinations
Dark Field Examination
We will be glad to advise with you concerning any laboratory problem
Sterile Containers sent on request
E. T. MANNING, B. S., M. D., Mgr.
luiimiiiiiiiiiiiiiiiiuiiiiii
O
When writiriR to advertisers please mention The Journal of Iowa State Medical Society
The New York Academy of Medicine
This book must not be retained for
LONGER THAN ONE WEEK AFTER THE LAST
DATE ON THE SLIP UNLESS PERMISSION FOR ITS
RENEWAL E.E OBTAINED FROM THE LIBRARY. |
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